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Erkan B, Bayındır M, Akpınar E, Tanrıverdi O, Haşimoğlu O, Postalcı LŞ, Bugün DA, Tekin D, Çiftçi S, Çakır İ, Mert M, Günaldı Ö, Hatipoğlu E. Medium and Long-Term Data from a Series of 96 Endoscopic Transsphenoidal Surgeries for Cushing Disease. J Korean Neurosurg Soc 2024; 67:237-248. [PMID: 38449382 PMCID: PMC10924914 DOI: 10.3340/jkns.2023.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/06/2023] [Accepted: 11/06/2023] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVE Postoperative data on Cushing's disease (CD) are equivocal in the literature. These discrepancies may be attributed to different series with different criteria for remission and variable follow-up durations. Additional data from experienced centers may address these discrepancies. In this study, we present the results obtained from 96 endoscopic transsphenoidal surgeries (ETSSs) for CD conducted in a well-experienced center. METHODS Pre- and postoperative data of 96 ETSS in 87 patients with CD were included. All cases were handled by the same neurosurgical team between 2014 and 2022. We obtained data on remission status 3-6 months postoperatively (medium-term) and during the latest follow-up (long-term). Additionally, magnetic resonance imaging (MRI) and pathology results were obtained for each case. RESULTS The mean follow-up duration was 39.5±3.2 months. Medium and long-term remission rates were 77% and 82%, respectively. When only first-time operations were considered, the medium- and long-term remission rates were 78% and 82%, respectively. The recurrence rate in this series was 2.5%. Patients who showed remission between 3-6 months had higher longterm remission rates than did those without initial remission. Tumors >2 cm and extended tumor invasion of the cavernous sinus (Knosp 4) were associated with lower postoperative remission rates. CONCLUSION Adenoma size and the presence/absence of cavernous sinus invasion on preopera-tive MRI may predict long-term postoperative remission. A tumor size of 2 cm may be a supporting criterion for predicting remission in Knosp 4 tumors. Further studies with larger patient populations are necessary to support this finding.
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Affiliation(s)
- Buruç Erkan
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
| | - Muhammed Bayındır
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ebubekir Akpınar
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Osman Tanrıverdi
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ozan Haşimoğlu
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Didem Acarer Bugün
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Dilara Tekin
- Endocrinology and Metabolism Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Sema Çiftçi
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - İlkay Çakır
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Meral Mert
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Bakirkoy Dr. Sadi Konuk Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ömür Günaldı
- Neurosurgery Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
| | - Esra Hatipoğlu
- University of Health Sciences Pituitary Diseases Practice and Research Center (PDPRC), Istanbul, Turkey
- Endocrinology and Metabolism Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Webb KL, Hinkle ML, Walsh MT, Bancos I, Shinya Y, Van Gompel JJ. Inferior Petrosal Sinus Sampling Tumor Lateralization and the Surgical Treatment of Cushing Disease: A Meta-Analysis and Systematic Review. World Neurosurg 2024; 182:e712-e720. [PMID: 38081579 DOI: 10.1016/j.wneu.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVE To determine whether accurate inferior petrosal sinus sampling (IPSS) tumor lateralization is associated with improved clinical outcomes following the surgical treatment of Cushing disease. METHODS The presented study was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data regarding patient demographics, IPSS tumor lateralization, and postoperative endocrinologic outcomes were abstracted and pooled with random effects meta-analysis models. Additional meta-regression models were used to examine the association between the accuracy of IPSS tumor lateralization and postoperative outcomes (recurrence/persistence or remission/cure). Statistical analyses were performed using the Comprehensive Meta-Analysis software (significance of P < 0.05). RESULTS Seventeen eligible articles were identified, yielding data on 461 patients. Within average follow-up duration (∼59 months), the rate of correct IPSS tumor lateralization was 69% [95% confidence interval: 61%, 76%], and the rate of postoperative remission/cure was 78% [67%, 86%]. Preoperative IPSS tumor lateralization was concordant with magnetic resonance imaging lateralization for 53% of patients [40%, 66%]. There was no significant association between the rate of correct IPSS tumor lateralization and postoperative remission/cure among study-level data (P = 0.735). Additionally, there was no association among subgroup analyses for studies using stimulatory agents during IPSS (corticotropin-releasing hormone or desmopressin, P = 0.635), nor among subgroup analyses for adult (P = 0.363) and pediatric (P = 0.931) patients. CONCLUSIONS Limited data suggest that the rate of correct IPSS tumor lateralization may not be positively associated with postoperative remission or cure in patients with Cushing disease. These findings bring into question the utility of IPSS tumor lateralization in the context of preoperative planning and surgical approach rather than confirming a pituitary source.
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Affiliation(s)
- Kevin L Webb
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Mickayla L Hinkle
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael T Walsh
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Sun H, Wu C, Hu B, Xiao Y. Interpetrosal sphingosine-1-phosphate ratio predicting Cushing's disease tumor laterality and remission after surgery. Front Endocrinol (Lausanne) 2023; 14:1238573. [PMID: 38027207 PMCID: PMC10644774 DOI: 10.3389/fendo.2023.1238573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Cushing's disease (CD) poses significant challenges in its treatment due to the lack of reliable biomarkers for predicting tumor localization or postoperative clinical outcomes. Sphingosine-1-phosphate (S1P) has been shown to increase cortisol biosynthesis and is regulated by adrenocorticotropic hormone (ACTH). Methods We employed bilateral inferior petrosal sinus sampling (BIPSS), which is considered the gold standard for diagnosing pituitary sources of CD, to obtain blood samples and explore the clinical predictive value of the S1P concentration ratio in determining tumor laterality and postoperative remission. We evaluated 50 samples from 25 patients who underwent BIPSS to measure S1P levels in the inferior petrosal sinuses bilaterally. Results Serum S1P levels in patients with CD were significantly higher on the adenoma side of the inferior petrosal sinus than on the nonadenoma side (397.7 ± 15.4 vs. 261.9 ± 14.88; P < 0.05). The accuracy of diagnosing tumor laterality with the interpetrosal S1P and ACTH ratios and the combination of the two was 64%, 56% and 73%, respectively. The receiver operating characteristic curve analysis revealed that the combination of interpetrosal S1P and ACTH ratios, as a predictor of tumor laterality, exhibited a sensitivity of 81.82% and a specificity of 75%, with an area under the curve value of 84.09%. Moreover, we observed that a high interpetrosal S1P ratio was associated with nonremission after surgery. Correlation analyses demonstrated that the interpetrosal S1P ratio was associated with preoperative follicle-stimulating hormone (FSH), luteinizing hormone (LH), and postoperative ACTH 8 am levels (P < 0.05). Conclusion Our study demonstrated a significant association between the interpetrosal S1P ratio and tumor laterality, as well as postoperative remission in CD, suggesting that the interpetrosal S1P ratio could serve as a valuable biomarker in clinical practice.
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Affiliation(s)
- Heng Sun
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chunli Wu
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Biao Hu
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuan Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, Hunan, China
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Ünal M, Selek A, Sözen M, Gezer E, Köksalan D, Canturk Z, Cetinarslan B, Çabuk B, Anık I, Ceylan S. Recurrent Cushing's Disease in Adults: Predictors and Long-Term Follow-Up. Horm Metab Res 2023; 55:520-527. [PMID: 37015254 DOI: 10.1055/a-2047-6017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Cushing's disease (CD) is characterized by endogenous hypercortisolism that is associated with increased mortality and morbidity. Due to high recurrence rates in CD, the determination of high-risk patients is of paramount importance. In this study, we aimed to determine recurrence rates and clinical, laboratory, and histological predictors of recurrence in a high volume single-center. This retrospective study included 273 CD patients operated in a single pituitary center between 1997 and 2020. The patients with early postoperative remission were further grouped according to recurrence status (recurrent and sustained remission groups). Demographic, radiologic, laboratory, pathologic, and follow-up clinical data of the patients were analyzed and compared between groups. The recurrence rate was 9.6% in the first 5 years; however, the overall recurrence rate was 14.2% in this study. Higher preoperative basal ACTH levels were significantly correlated with CD recurrence even with ACTH levels adjusted for tumor size, Ki-67 levels, and tumoral invasion. Recurrence rates were significantly higher in patients with ACTH levels higher than 55 pg/ml, tumor diameter>9.5 mm, and if adrenal axis recovery was before 6 months. The severity of hypercortisolism, morbidities, and demographic factors except age were not predictive factors of recurrence. Based on our study data, younger age at diagnosis, a diagnosis of osteoporosis, higher preoperative ACTH levels, larger tumor size, invasive behavior, higher Ki 67 index, and early recovery of the adrenal axis during the postoperative period attracted attention as potential predictors of recurrent disease.
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Affiliation(s)
- Mustafa Ünal
- Department of Internal Medicine, Kocaeli University, Kocaeli, Turkey
| | - Alev Selek
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Mehmet Sözen
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Emre Gezer
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Damla Köksalan
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Zeynep Canturk
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Berrin Cetinarslan
- Department of Endocrinology and Metabolism, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Burak Çabuk
- Department of Neurosurgery, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Ihsan Anık
- Department of Neurosurgery, Pituitary Center, Kocaeli University, Kocaeli, Turkey
| | - Savaş Ceylan
- Department of Neurosurgery, Pituitary Center, Kocaeli University, Kocaeli, Turkey
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Feola T, Pirchio RS, Puliani G, Pofi R, Crocco M, Sada V, Sesti F, Verdecchia F, Gianfrilli D, Appetecchia M, Di Iorgi N, Jaffrain-Rea ML, Pivonello R, Isidori AM, Grossman AB, Sbardella E. Sellar and parasellar lesions in the transition age: a retrospective Italian multi-centre study. J Endocrinol Invest 2023; 46:181-188. [PMID: 36001286 PMCID: PMC9829590 DOI: 10.1007/s40618-022-01900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/09/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Sellar/parasellar lesions have been studied in the adult and paediatric age range, but during the transition age their epidemiology, clinical manifestations, management and treatment outcomes have been poorly investigated. MATERIALS AND METHODS An Italian multicentre cohort study, in which hospital records of patients with diagnosis of sellar/parasellar lesions during the transition age and young adulthood (15-25 years), were reviewed in terms of prevalence, clinical and hormonal features at diagnosis, and outcomes where available. Both pituitary neuroendocrine tumours (pituitary tumours, Group A) and non-endocrine lesions (Group B) were included. RESULTS Among Group A (n = 170, 46.5% macroadenomas), the most frequent were prolactin and GH-secreting tumours, with a female predominance. Among Group B (n = 28), germinomas and Rathke cells cysts were the most common. In Group A, the most frequent hormonal deficiency was gonadal dysfunction. Galactorrhoea and amenorrhoea were relatively common in female patients with prolactinomas. Pre-surgical diabetes insipidus was only seen in Group B, in which also hormone deficiencies were more frequent and numerous. Larger lesions were more likely to be seen in Group B. Patients in Group B were more frequently male, younger, and leaner than those of Group A, whereas at last follow-up they showed more obesity and dyslipidaemia. In our cohort, the percentage of patients with at least one pituitary deficiency increased slightly after surgery. CONCLUSIONS The management of sellar/parasellar lesions is challenging in the transition age, requiring an integrated and multidisciplinary approach. Hormone and metabolic disorders can occur many years after treatment, therefore long-term follow-up is mandatory.
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Affiliation(s)
- T Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
| | - R Sa Pirchio
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Degli Studi di Napoli "Federico II", Naples, Italy
| | - G Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - R Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - M Crocco
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - V Sada
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - F Sesti
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - F Verdecchia
- Dipartimento Pediatrico Universitario Ospedaliero, Bambino Gesù Children Hospital, Rome, Italy
| | - D Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - M Appetecchia
- Oncological Endocrinology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - N Di Iorgi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - M L Jaffrain-Rea
- Neuroendocrinology, Neuromed Institute, IRCCS, Pozzilli, Italy
- Department of Biotechnological and Applied Clinical Sciences, University of L' Aquila, L'Aquila, Italy
| | - R Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Degli Studi di Napoli "Federico II", Naples, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - A B Grossman
- Green Templeton College, University of Oxford, Oxford, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, UK
| | - E Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Wang B, Zheng S, Ren J, Zhong Z, Jiang H, Sun Q, Su T, Wang W, Sun Y, Bian L. Reoperation for Recurrent and Persistent Cushing's Disease without Visible MRI Findings. J Clin Med 2022; 11:jcm11226848. [PMID: 36431325 PMCID: PMC9699622 DOI: 10.3390/jcm11226848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Transsphenoidal surgery is the first-line treatment for Cushing's disease (CD), even with negative preoperative magnetic resonance imaging (MRI) results. Some patients with persistent or recurring hypercortisolism have negative MRI findings after the initial surgery. We aimed to analyze the efficacy of repeat surgery in two groups of patients and determine if there is an association between positive MRI findings and early remission. PATIENTS AND METHODS Clinical, imaging, and biochemical information of 42 patients who underwent repeat surgery by a single neurosurgeon between 2002 and 2021 was retrospectively analyzed. We compared the endocrinological, histopathological, and surgical outcomes before and after repeat surgery among 14 CD patients with negative MRI findings and 28 patients with positive MRI findings. RESULTS Immediate remission was achieved in 29 patients (69.0%) who underwent repeat surgery. Among all patients, 28 (66.7%) had MRI findings consistent with solid lesions. There was no significant difference in remission rates between the recurrence and persistence groups (77.8% vs. 57.1%, odds ratio = 2.625, 95% confidence interval = 0.651 to 10.586). Patients in remission after repeat surgery were not associated with positive MRI findings (odds ratio = 3.667, 95% confidence interval = 0.920 to 14.622). CONCLUSIONS In terms of recurrence, repeat surgery in patients with either positive or negative MRI findings showed reasonable remission rates. For persistent disease with positive MRI findings, repeat surgery is still an option; however, more solid evidence is needed to determine if negative MRI findings are predictors for failed reoperations for persistent hypercortisolism.
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Affiliation(s)
- Baofeng Wang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuying Zheng
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jie Ren
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhihong Zhong
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hong Jiang
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qingfang Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Tingwei Su
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Weiqing Wang
- Department of Endocrinology and Metabolic Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yuhao Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
| | - Liuguan Bian
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
- Correspondence: (Y.S.); or (L.B.)
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7
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Guignat L, Bertherat J. Long-term follow-up and predictors of recurrence of Cushing's disease. J Neuroendocrinol 2022; 34:e13186. [PMID: 35979714 DOI: 10.1111/jne.13186] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022]
Abstract
Transsphenoidal surgery is the first-line treatment for Cushing's disease to selectively remove the tumor. The rate of postoperative remission is estimated around 70%-80% in expert centers. However, the long-term remission rate is lower because of recurrence during follow-up that can be observed in 15% to 25% of the patients depending on the studies and duration of follow-up. There is no significant predictive factor of recurrence before surgery, but postoperative corticotroph insufficiency and its duration has been found to be a protective factor for recurrence in many studies. The persistence of a positive response to desmopressin after surgery is associated with a higher rate of recurrence. Long term monitoring for recurrence with annual clinical and hormonal investigations after the hypothalamic-pituitary-adrenal axis postoperative recovery is advised. The biological tests used for the diagnosis of Cushing's syndrome (24 h-urinary-free cortisol [UFC], late-night salivary or serum cortisol, 1 mg dexamethasone suppression test) can be used to screen for recurrence. Several studies report that increased late night cortisol and alterations of dynamic testing can be observed before the increased 24 h-UFC. For this reason it is suggested that late-night salivary cortisol would be a very sensitive tool to diagnose recurrence, pending the realization of several assays in case of borderline or discrepant result. This review will summarize the knowledge about recurrence of Cushing's disease after pituitary surgery and the current recommendations for its monitoring and diagnosis.
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Affiliation(s)
- Laurence Guignat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jérôme Bertherat
- Department of Endocrinology and National Reference Center for Rare Adrenal Disorders, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Institut Cochin, Inserm U1016, CNRS UMR8104, Paris, France
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8
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Yang AB, Henderson F, Schwartz TH. Surgical strategies in the treatment of MR-negative Cushing's Disease: a systematic review and treatment algorithm. Pituitary 2022; 25:551-562. [PMID: 35710682 DOI: 10.1007/s11102-022-01239-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Several surgical strategies have been proposed to treat MRI-negative Cushing's Disease. These include tumor removal, if identified, and if a tumor is not identified, resection of varying degrees of the pituitary gland, often guided by inferior petrosal sinus sampling (IPSS). The relative risks and benefits of each strategy have never been compared. METHODS This systematic review of the literature included only studies on the results of surgery for MRI-negative patients with Cushing's Disease in which the surgical strategy was clearly described and associated remission and/or hypopituitarism rates detailed for each strategy. RESULTS We identified 12 studies that met inclusion criteria for remission rates and 5 studies for hypopituitarism rates. We divided cases into 6 resection strategies. Remission and hypopituitarism rates for each strategy were: (1) tumor identified, resect tumor only (68%, 0%); (2) resect tumor and surrounding capsule (85%, 0%); and if the tumor was not identified (3) resect inferior 1/3 of gland (78%, no data); (4) resect 30-50% of gland based on IPSS (68%, 13%); (5) resect > 50% but < 100% of gland (65%, 9%); (6) resect entire gland (66%, 67%). Strategy 3 only contained 9 patients. CONCLUSION Remission rates for MRI-negative Cushing's Disease support surgery as a reasonable approach. Results are best if a tumor is found. If a tumor is not identified, one can either remove one-third of the gland guided by IPSS lateralization, or remove both lateral portions along with the inferior portion leaving sufficient central gland to preserve function. Our recommendations are limited by the lack of rigorous and objective data.
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Affiliation(s)
| | - Fraser Henderson
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th St., Box #99, New York, NY, 10065, USA.
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9
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Limumpornpetch P, Morgan AW, Tiganescu A, Baxter PD, Nyawira Nyaga V, Pujades-Rodriguez M, Stewart PM. The Effect of Endogenous Cushing Syndrome on All-cause and Cause-specific Mortality. J Clin Endocrinol Metab 2022; 107:2377-2388. [PMID: 35486378 PMCID: PMC9282270 DOI: 10.1210/clinem/dgac265] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to perform a systematic review and meta-analysis of all-cause and cause-specific mortality of patients with benign endogenous Cushing syndrome (CS). METHODS The protocol was registered in PROSPERO (CRD42017067530). PubMed, EMBASE, CINHAL, Web of Science, and Cochrane Central searches were undertaken from inception to January 2021. Outcomes were the standardized mortality ratio (SMR), proportion, and cause of deaths. The I2 test, subgroup analysis, and meta-regression were used to assess heterogeneity across studies. RESULTS SMR was reported in 14 articles including 3691 patients (13 Cushing disease [CD] and 7 adrenal CS [ACS] cohorts). Overall SMR was 3.0 (95% CI, 2.3-3.9; I2 = 80.5%) for all CS, 2.8 (95% CI, 2.1-3.7; I2 = 81.2%) for CD and 3.3 (95% CI, 0.5-6.6; I2 = 77.9%) for ACS. Proportion of deaths, reported in 87 articles including 19 181 CS patients (53 CD, 24 ACS, and 20 combined CS cohorts), was 0.05 (95% CI, 0.03-0.06) for all CS subtypes with meta-regression analysis revealing no differences between CS subtypes (P = .052). The proportion of deaths was 0.1 (10%) in articles published before 2000 and 0.03 (3%) in 2000 until the last search for CS (P < .001), CD (P < .001), and ACS (P = .01). The causes of death were atherosclerotic diseases and thromboembolism (43.4%), infection (12.7%), malignancy (10.6%), active disease (3.5%), adrenal insufficiency (3.0%), and suicide (2.2%). Despite improved outcomes in recent years, increased mortality from CS persists. The causes of death highlight the need to prevent and manage comorbidities in addition to treating hypercortisolism.
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Affiliation(s)
- Padiporn Limumpornpetch
- School of Medicine, University of Leeds, Leeds LS2 9NL, UK
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand
| | - Ann W Morgan
- School of Medicine, University of Leeds, Leeds LS2 9NL, UK
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- NIHR Leeds Medtech and In-vitro Diagnostics Co-operative, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ana Tiganescu
- School of Medicine, University of Leeds, Leeds LS2 9NL, UK
| | - Paul D Baxter
- School of Medicine, University of Leeds, Leeds LS2 9NL, UK
| | | | | | - Paul M Stewart
- Correspondence: Paul M Stewart, MB ChB MD, FMedSci, University of Leeds, NEXUS, Discovery Way, Leeds, LS2 3AA, UK.
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Kuritsyna NV, Tsoy UA, Cherebillo VY, Paltsev AA, Ryzhkov AV, Ryazanov PA, Ryzhkov VK, Grineva EN. A Comprehensive Approach to Predicting the Outcomes of Transsphenoidal Endoscopic Adenomectomy in Patients with Cushing’s Disease. J Pers Med 2022; 12:jpm12050798. [PMID: 35629220 PMCID: PMC9144911 DOI: 10.3390/jpm12050798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/03/2022] [Accepted: 05/11/2022] [Indexed: 12/10/2022] Open
Abstract
Persistent and recurrent hypercortisolism after transsphenoidal endoscopic surgery (TSS) is considered to be an urgent issue prompting the search for Cushing’s disease (CD) remission predictors. The goal was to find a combination of predictors that can forecast the remission of CD after TSS. A total of 101 patients with CD who had undergone TSS were included. One year after surgery, CD remission status was evaluated. Preoperative pituitary magnetic resonance imaging (MRI) data, preoperative results of a high-dose dexamethasone suppression test (HDDST) and morning serum cortisol level collected 24 h after TSS (24 h MSeC) were compared in patients with and without remission of hypercortisolism. Remission one year after TSS was confirmed in 63 patients. CD remission predictors one year after TSS were: adenoma size ≥ 3 mm in the absence of invasive growth and the suppression of serum cortisol ≥ 74% in the HDDST, 24 h MSeC ≤ 388 nmol/L. A total of 38 patients had three favorable values of detected predictors; all of them had CD remission one year after TSS. With long-term follow-up, 36 of them remained in remission. Patients who had no one favorable predictor had no remission of hypercortisolism one year after TSS. Our data confirmed the prospects of using a combination of selected predictors to forecast CD remission after TSS.
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11
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Tabarin A, Assié G, Barat P, Bonnet F, Bonneville JF, Borson-Chazot F, Bouligand J, Boulin A, Brue T, Caron P, Castinetti F, Chabre O, Chanson P, Corcuff JB, Cortet C, Coutant R, Dohan A, Drui D, Espiard S, Gaye D, Grunenwald S, Guignat L, Hindie E, Illouz F, Kamenicky P, Lefebvre H, Linglart A, Martinerie L, North MO, Raffin-Samson ML, Raingeard I, Raverot G, Raverot V, Reznik Y, Taieb D, Vezzosi D, Young J, Bertherat J. Consensus statement by the French Society of Endocrinology (SFE) and French Society of Pediatric Endocrinology & Diabetology (SFEDP) on diagnosis of Cushing's syndrome. ANNALES D'ENDOCRINOLOGIE 2022; 83:119-141. [PMID: 35192845 DOI: 10.1016/j.ando.2022.02.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Cushing's syndrome is defined by prolonged exposure to glucocorticoids, leading to excess morbidity and mortality. Diagnosis of this rare pathology is difficult due to the low specificity of the clinical signs, the variable severity of the clinical presentation, and the difficulties of interpretation associated with the diagnostic methods. The present consensus paper by 38 experts of the French Society of Endocrinology and the French Society of Pediatric Endocrinology and Diabetology aimed firstly to detail the circumstances suggesting diagnosis and the biologic diagnosis tools and their interpretation for positive diagnosis and for etiologic diagnosis according to ACTH-independent and -dependent mechanisms. Secondly, situations making diagnosis complex (pregnancy, intense hypercortisolism, fluctuating Cushing's syndrome, pediatric forms and genetically determined forms) were detailed. Lastly, methods of surveillance and diagnosis of recurrence were dealt with in the final section.
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Affiliation(s)
- Antoine Tabarin
- Service Endocrinologie, Diabète et Nutrition, Université, Hôpital Haut-Leveque CHU de Bordeaux, 33604 Pessac, France.
| | - Guillaume Assié
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Pascal Barat
- Unité d'Endocrinologie-Diabétologie-Gynécologie-Obésité Pédiatrique, Hôpital des Enfants CHU Bordeaux, Bordeaux, France
| | - Fidéline Bonnet
- UF d'Hormonologie Hôpital Cochin, Université de Paris, Institut Cochin Inserm U1016, CNRS UMR8104, Paris, France
| | | | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Hôpital Louis-Pradel, Hospices Civils de Lyon, INSERM U1290, Université Lyon1, 69002 Lyon, France
| | - Jérôme Bouligand
- Faculté de Médecine Paris-Saclay, Unité Inserm UMRS1185 Physiologie et Physiopathologie Endocriniennes, Paris, France
| | - Anne Boulin
- Service de Neuroradiologie, Hôpital Foch, 92151 Suresnes, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Philippe Caron
- Service d'Endocrinologie et Maladies Métaboliques, Pôle Cardiovasculaire et Métabolique, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France
| | - Frédéric Castinetti
- Aix-Marseille Université, Institut National de la Recherche Scientifique (INSERM) U1251, Marseille Medical Genetics, Marseille, France; Assistance publique-Hôpitaux de Marseille, Service d'Endocrinologie, Hôpital de la Conception, Centre de Référence Maladies Rares HYPO, 13005 Marseille, France
| | - Olivier Chabre
- Université Grenoble Alpes, UMR 1292 INSERM-CEA-UGA, Endocrinologie, CHU Grenoble Alpes, 38000 Grenoble, France
| | - Philippe Chanson
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse HYPO, Le Kremlin-Bicêtre, France
| | - Jean Benoit Corcuff
- Laboratoire d'Hormonologie, Service de Médecine Nucléaire, CHU Bordeaux, Laboratoire NutriNeuro, UMR 1286 INRAE, Université de Bordeaux, Bordeaux, France
| | - Christine Cortet
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, CHU de Lille, Lille, France
| | - Régis Coutant
- Service d'Endocrinologie Pédiatrique, CHU Angers, Centre de Référence, Centre Constitutif des Maladies Rares de l'Hypophyse, CHU Angers, Angers, France
| | - Anthony Dohan
- Department of Radiology A, Hôpital Cochin, AP-HP, 75014 Paris, France
| | - Delphine Drui
- Service Endocrinologie-Diabétologie et Nutrition, l'institut du Thorax, CHU Nantes, 44092 Nantes cedex, France
| | - Stéphanie Espiard
- Service d'Endocrinologie, Diabétologie, Métabolisme et Nutrition, INSERM U1190, Laboratoire de Recherche Translationnelle sur le Diabète, 59000 Lille, France
| | - Delphine Gaye
- Service de Radiologie, Hôpital Haut-Lêveque, CHU de Bordeaux, 33604 Pessac, France
| | - Solenge Grunenwald
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Laurence Guignat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Elif Hindie
- Service de Médecine Nucléaire, CHU de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Frédéric Illouz
- Centre de Référence Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Service Endocrinologie-Diabétologie-Nutrition, CHU Angers, 49933 Angers cedex 9, France
| | - Peter Kamenicky
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Hervé Lefebvre
- Service d'Endocrinologie, Diabète et Maladies Métaboliques, CHU de Rouen, Rouen, France
| | - Agnès Linglart
- Paris-Saclay University, AP-HP, Endocrinology and Diabetes for Children, Reference Center for Rare Disorders of Calcium and Phosphate Metabolism, Filière OSCAR, and Platform of Expertise for Rare Disorders, INSERM, Physiologie et Physiopathologie Endocriniennes, Bicêtre Paris-Saclay Hospital, Le Kremlin-Bicêtre, France
| | - Laetitia Martinerie
- Service d'Endocrinologie Pédiatrique, CHU Robert-Debré, AP-HP, Paris, France; Université de Paris, Paris, France
| | - Marie Odile North
- Service de Génétique et Biologie Moléculaire, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Marie Laure Raffin-Samson
- Service d'Endocrinologie Nutrition, Hôpital Ambroise-Paré, GHU Paris-Saclay, AP-HP Boulogne, EA4340, Université de Versailles-Saint-Quentin, Paris, France
| | - Isabelle Raingeard
- Maladies Endocriniennes, Hôpital Lapeyronie, CHU Montpellier, Montpellier, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence Maladies Rares Hypophysaires, "Groupement Hospitalier Est", Hospices Civils de Lyon, Lyon, France
| | - Véronique Raverot
- Hospices Civils de Lyon, LBMMS, Centre de Biologie Est, Service de Biochimie et Biologie Moléculaire, 69677 Bron cedex, France
| | - Yves Reznik
- Department of Endocrinology and Diabetology, CHU Côte-de-Nacre, 14033 Caen cedex, France; University of Caen Basse-Normandie, Medical School, 14032 Caen cedex, France
| | - David Taieb
- Aix-Marseille Université, CHU La Timone, AP-HM, Marseille, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Hôpital Larrey, CHU Toulouse, Toulouse, France
| | - Jacques Young
- Assistance publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, 94275 Le Kremlin-Bicêtre, France
| | - Jérôme Bertherat
- Centre de Référence Maladies Rares de la Surrénale (CRMRS), Service d'Endocrinologie, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
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12
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Dai C, Feng M, Sun B, Bao X, Yao Y, Deng K, Ren Z, Zhao B, Lu L, Wang R, Kang J. Surgical outcome of transsphenoidal surgery in Cushing's disease: a case series of 1106 patients from a single center over 30 years. Endocrine 2022; 75:219-227. [PMID: 34415482 DOI: 10.1007/s12020-021-02848-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the first-line treatment for patients with Cushing's disease (CD). However, the reported remission rates of patients who received TSS vary widely between different studies, and the predictors of surgical outcomes remain controversial. The present study analyzed the early outcome of TSS in a large population of patients with CD at a single center, and identified potential predictors of initial remission of TSS in patients with CD. METHODS The clinical features and surgical outcomes of CD patients who underwent TSS between 1988 and 2018 at Peking Union Medical College Hospital (PUMCH) were collected and analyzed from their medical records. RESULTS Of the 1604 CD patients who underwent TSS at PUMCH between February 1988 and October 2018, 1106 patients had complete medical data and pathological results. After surgery, the overall postoperative initial remission rate was 72.5, and 27.5% of patients maintained persistent hypercortisolism. The initial remission rate of patients with preoperative noninvasive adenoma based on MRI (77.1%), intraoperative noninvasiveness (72.5%), microadenoma (74.3%), pathological confirmation (76.4%), and first TSS (73.9%) was significantly higher than that in patients with preoperative invasive adenoma (53.0%), intraoperative invasiveness (60.7%), macroadenomas (65.9%), pathologically negative (49.7%), and repeat TSS (56.0%), respectively (all P < 0.05). The initial remission rate in patients with pseudocapsule-based extracapsular resection (88.1%), MRI-visible adenoma (74.2%) was higher than that in patients without pseudocapsule-based extracapsular resection (77.1%), and with MRI-negative results (64.5%), respectively, but did not reach statistical significance (All P > 0.05). Striking, there was no significant differences in initial remission rates between patients who underwent selective adenomectomy and enlarged adenomectomy (P > 0.05). Whereas, the initial remission rates in patients who underwent partial hypophysectomy only was 51.0%, which was much lower than that in patients underwent selective adenomectomy and enlarged adenomectomy (P < 0.05). CONCLUSION The TSS is a safe and effective procedure for the treatment of CD. Whereas, preoperative invasiveness based on MRI, intraoperative invasiveness, macroadenomas pathologically negative, and repeat TSS are related to lower initial remission rates.
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Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Sun
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zuyuan Ren
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Binghao Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jun Kang
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China.
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13
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Andereggen L, Mariani L, Beck J, Andres RH, Gralla J, Luedi MM, Weis J, Christ E. Lateral one-third gland resection in Cushing patients with failed adenoma identification leads to low remission rates: long-term observations from a small, single-center cohort. Acta Neurochir (Wien) 2021; 163:3161-3169. [PMID: 33811521 PMCID: PMC8520517 DOI: 10.1007/s00701-021-04830-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Currently, there are no guidelines for neurosurgeons treating patients with Cushing's disease (CD) when intraoperative adenoma identification is negative. Under these circumstances, a total hypophysectomy or hemi-hypophysectomy on the side indicated by inferior petrosal sinus sampling (IPSS) is the approach being used, although there is a subsequent risk of hypopituitarism. Data on whether one-third lateral pituitary gland resection results in cure of hypercortisolism and low rates of hypopituitarism remain inconclusive. METHODS Retrospective single-center study of CD patients with failed intraoperative adenoma identification and subsequent resection of the lateral one-third of the pituitary gland as predicted by IPSS. We assessed (i) histopathological findings, (ii) early and long-term remission rates, and (iii) rates of additional pituitary hormone insufficiency. RESULTS Ten women and three men met the inclusion criteria. At 3 months, remission was noted in six (46%) patients: three (23%) had histologically confirmed adenomas, two (15%) had ACTH hyperplasia, and one patient (8%) was positive for Crooke's hyaline degeneration. New pituitary hormone deficits were noted in two patients (15%). After a median (±SD) follow-up of 14±4 years, recurrence was noted in two (15%) patients. Long-term control of hypercortisolism was attained by 10 patients (77%), with additional therapies required in nine (69%) of them. CONCLUSIONS In CD patients with failed intraoperative adenoma visualization, lateral one-third gland resection resulted in low morbidity and long-term remission in 31% of patients without the need for additional therapies. Bearing in mind the sample size of this audit, the indication for lateral one-third-gland resection has to be critically appraised and discussed with the patients before surgery.
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Affiliation(s)
- Lukas Andereggen
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland.
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Robert H Andres
- Department of Neurosurgery, Neurocenter and Regenerative Neuroscience Cluster, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joachim Weis
- Institute of Neuropathology, RWTH Aachen University Hospital, Aachen, Germany
| | - Emanuel Christ
- Department of Endocrinology, Diabetology and Metabolism, University Hospital of Basel, Basel, Switzerland
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14
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Abdali A, Kalinin PL, Trunin YY, Astaf'Eva LE, Shkarubo AN, Chmutin GE, Chavda V, Golanov A, Abdali B, Chernov IV, Vats A, Chaurasia B. CyberKnife for the management of Cushing's disease: our institutional experience and review of literature. Br J Neurosurg 2021; 35:578-583. [PMID: 33955316 DOI: 10.1080/02688697.2021.1921107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Surgery is the primary treatment for Cushing's disease(CD). In cases with no biochemical remission after surgical resection or when recurrence occurs after a period of remission stereotactic radiosurgery (SRS) is used as alternative/adjuvant treatment. The aim of this study is to demonstrate the effectiveness of SRS and FSRS(Fractionated stereotactic radiosurgery) for the treatment of CD in a long term follow up. METHODS This is a retrospective study in which 41 patient (36 females and 5 males) who underwent surgery for CD from 2009 to 2019 were included. Out of 41 cases, 34 cases had microadenomas while 7 had macroadenomas. These patients had recurrence or persistence of hypercortisolism post-operatively. After multidisciplinary evaluation, these patients were treated by CyberKnife (SRS & FSRS). RESULTS Remission rate in our study was 60.97% with a median follow up period of 79.03 months. The median time to biochemical remission was 14 months. Tumour growth control was achieved in 95.12%. Hypopituitarism of different axes was seen in 34.14% patients. Secondary hypothyroidism was the most common pituitary insufficiency (34%) followed by secondary hypogonadism in 17%. CONCLUSION CyberKnife radiosurgery and hypofractionated radiosurgery can be used as an adjuvant treatment in patient with active disease and no biochemical remission after one or multiple surgical resections. Risk of radiation induced hypopituitarism and other complication is relatively low 34.14% and tumour growth control is significantly higher.
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Affiliation(s)
- Ashraf Abdali
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Pavel L Kalinin
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Yuriy Y Trunin
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Ludmila E Astaf'Eva
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Alexey N Shkarubo
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | | | | | - Andrey Golanov
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | | | - Ilya V Chernov
- N.N. Burdenko National Medical Research Centre of Neurosurgery, Moscow, Russia
| | - Atul Vats
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
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15
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Dai C, Liang S, Liu X, Fan Y, Bao X, Yao Y, Deng K, Lu L, Wang R, Feng M. Outcomes of Transsphenoidal Surgery in Cushing Disease Patients with Negative Pituitary Magnetic Resonance Imaging Findings: A Single-Center Experience. Endocr Pract 2021; 26:1320-1330. [PMID: 33471663 DOI: 10.4158/ep-2020-0177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/05/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is a first-line treatment for Cushing disease (CD). However, a subset of patients with CD have no visible adenoma on magnetic resonance imaging (MRI), and whether MRI results affect surgical outcomes is controversial. The aim of this study was to compare the surgical outcomes of CD patients with negative MRI findings to those of patients with positive MRI findings. METHODS The clinical features and outcomes of CD patients who underwent TSS between January 2000 and July 2019 at Peking Union Medical College Hospital were collected from medical records. The clinical, endocrinologic, histopathologic, surgical outcomes, and a minimum 12-month follow-up of 125 consecutive CD patients with negative MRI findings were compared with those of 1,031 consecutive CD patients with MRI-visible adenomas. RESULTS The total remission rate was 73.3% after TSS, and 11.8% of patients experienced recurrence. Of 1,031 patients with MRI-visible adenomas, postoperative remission was achieved in 762 patients (73.9%), and the recurrence of CD was observed in 94 (12.3%) patients. Of the 125 patients with negative MRI findings, postoperative remission was achieved in 85 (68%) patients, and recurrence was observed in 6 (7.1%) patients. The remission rate and recurrence rate were not significantly different between patients with negative MRI findings and those with positive MRI findings (all P>.05). The remission rate was not significantly different between patients who did or did not undergo bilateral inferior petrosal sinus sampling (BIPSS) in patients with negative MRI findings (P>.05). In the patients with negative MRI findings who underwent BIPSS, the remission rate of patients with positive BIPSS results was not different from that in patients with negative BIPSS results (P>.05). The lack of prior TSS, the detection of a tumor during operation, and pathologic confirmation of adenoma were associated with a higher surgical remission rate in patients with negative MRI findings (all P<.05). Similar results were observed in the patients with positive MRI findings (all P<.05). In addition, the major perioperative complications, including intraoperative cerebrospinal fluid leakage, hypopituitarism, and transient diabetes insipidus, were not related to the MRI results (all P>.05). CONCLUSION The remission rate and recurrence rate were not different between patients with negative MRI findings and those with positive MRI findings. If CD is clearly diagnosed according to biochemical tests, radiologic examinations, and BIPSS, we recommend TSS as the first-line treatment for patients, even if the MRI results are negative.
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Affiliation(s)
- Congxin Dai
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China; Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Siyu Liang
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yanghua Fan
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Xinjie Bao
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Kan Deng
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China.
| | - Ming Feng
- From the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical, Sciences and Peking Union Medical College, Beijing, China.
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16
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Zhang W, Sun M, Fan Y, Wang H, Feng M, Zhou S, Wang R. Machine Learning in Preoperative Prediction of Postoperative Immediate Remission of Histology-Positive Cushing's Disease. Front Endocrinol (Lausanne) 2021; 12:635795. [PMID: 33737912 PMCID: PMC7961560 DOI: 10.3389/fendo.2021.635795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There are no established accurate models that use machine learning (ML) methods to preoperatively predict immediate remission after transsphenoidal surgery (TSS) in patients diagnosed with histology-positive Cushing's disease (CD). PURPOSE Our current study aims to devise and assess an ML-based model to preoperatively predict immediate remission after TSS in patients with CD. METHODS A total of 1,045 participants with CD who received TSS at Peking Union Medical College Hospital in a 20-year period (between February 2000 and September 2019) were enrolled in the present study. In total nine ML classifiers were applied to construct models for the preoperative prediction of immediate remission with preoperative factors. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the performance of the models. The performance of each ML-based model was evaluated in terms of AUC. RESULTS The overall immediate remission rate was 73.3% (766/1045). First operation (p<0.001), cavernous sinus invasion on preoperative MRI(p<0.001), tumour size (p<0.001), preoperative ACTH (p=0.008), and disease duration (p=0.010) were significantly related to immediate remission on logistic univariate analysis. The AUCs of the models ranged between 0.664 and 0.743. The highest AUC, i.e., the best performance, was 0.743, which was achieved by stacking ensemble method with four factors: first operation, cavernous sinus invasion on preoperative MRI, tumour size and preoperative ACTH. CONCLUSION We developed a readily available ML-based model for the preoperative prediction of immediate remission in patients with CD.
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Affiliation(s)
- Wentai Zhang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengke Sun
- Medical Imaging, Robotics, Analytic Computing Laboratory/Engineering (MIRACLE), Key Laboratory of Intelligent Information Processing of Chinese Academy of Sciences (CAS), Institute of Computing Technology, CAS, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - He Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
| | - Shaohua Zhou
- Medical Imaging, Robotics, Analytic Computing Laboratory/Engineering (MIRACLE), Key Laboratory of Intelligent Information Processing of Chinese Academy of Sciences (CAS), Institute of Computing Technology, CAS, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Ming Feng, ; Shaohua Zhou, ; Renzhi Wang,
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Dai C, Fan Y, Liu X, Bao X, Yao Y, Wang R, Feng M. Predictors of Immediate Remission after Surgery in Cushing's Disease Patients: A Large Retrospective Study from a Single Center. Neuroendocrinology 2021; 111:1141-1150. [PMID: 32512562 DOI: 10.1159/000509221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Transsphenoidal surgery (TSS) is the first-line treatment of patients with Cushing's disease (CD). However, biochemical remission rates after TSS for CD vary from 59 to 95%, and the predictors of surgical outcomes remain unclear. The aim of this study was to identify the predictors of early outcomes in patients with CD treated with TSS. METHODS The clinical features and outcomes of CD patients who underwent TSS between February 2000 and September 2019 at the Peking Union Medical College Hospital were collected from medical records and analyzed. Uni- and multivariate odds ratio (OR) analyses were performed to identify the predictors of early outcomes in patients with CD. RESULTS A total of 1,045 patients were included. The median age at TSS was 34.0 years (IQR 26.0-45.0), with a female:male ratio of 4.2:1 (844/201). The median duration of symptoms was 46.0 months (IQR 24.0-72.0). After surgery, the overall postoperative immediate remission rate was 73.3%, and 26.7% of patients had persistent hypercortisolism. Univariate analysis demonstrated that the number of operations was correlated with a lower immediate remission rate (OR 0.393, 95% CI 0.266-0.580, p = 0.000), as was tumor size (OR 0.462, 95% CI 0.334-0.639, p = 0.000), the duration of disease (OR 0.996, 95% CI 0.993-0.999, p = 0.003), and preoperative ACTH concentration (0.998, 95% CI 0.996-0.999, p = 0.003). Cavernous sinus invasion has also been identified as an important factor associated with a lower immediate remission rate (OR 0.275, 95% CI 0.166-0.456, p = 0.000). No correlations were detected between the immediate outcomes and age, gender, BMI, the combination of a low- and high-dose dexamethasone suppression test, preoperative morning serum cortisol level, or 24-h urinary free cortisol level (all p > 0.05). The results of multivariate analysis were similar to those of univariate analysis. Preoperative ACTH ≤67.35 ng/L predicted remission with 60.9% sensitivity and 49.5% specificity (AUC 0.553; p = 0.008). A cutoff of ≤64.5 months for disease duration predicted immediate remission with 40.5% sensitivity and 71.0% specificity (AUC 0.552; p = 0.01). CONCLUSION Early outcomes of TSS in CD patients can be predicted by factors including the number of operations, duration of disease, tumor invasion, tumor size, and preoperative ACTH concentration. These predictors can be used to improve the perioperative management of CD patients.
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Affiliation(s)
- Congxin Dai
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yanghua Fan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
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Perosevic M, Jones PS, Tritos NA. Magnetic resonance imaging of the hypothalamo-pituitary region. HANDBOOK OF CLINICAL NEUROLOGY 2021; 179:95-112. [PMID: 34225987 DOI: 10.1016/b978-0-12-819975-6.00004-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The diagnosis and management of mass lesions in the sellar and parasellar areas remain challenging. When approaching patients with possible sellar or hypothalamic masses, it is important not only to focus on imaging but also detect possible pituitary hormone deficits or excess, in order to establish an appropriate diagnosis and initiate treatment. The imaging modalities used to characterize hypothalamic and pituitary lesions have significantly evolved over the course of the past several years. Computed tomography (CT) and CT angiography play a major role in detecting various sellar lesions, especially in patients who have contraindications to magnetic resonance imaging (MRI) and can also yield important information for surgical planning. However, MRI has become the gold standard for the detection and characterization of hypothalamic and pituitary tumors, infections, cystic, or vascular lesions. Indeed, the imaging characteristics of hypothalamic and sellar lesions can help narrow down the differential diagnosis preoperatively. In addition, MRI can help establish the relationship of mass lesions to surrounding structures. A pituitary MRI examination should be obtained if there is concern for mass effect (including visual loss, ophthalmoplegia, headache) or if there is clinical suspicion and laboratory evidence of either hypopituitarism or pituitary hormone excess. The information obtained from MRI images also provides us with assistance in planning surgery. Using intraoperative MRI can be very helpful in assessing the adequacy of tumor resection. In addition, MRI images yield reliable data that allow for noninvasive monitoring of patients postoperatively.
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Affiliation(s)
- Milica Perosevic
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Pamela S Jones
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Senanayake R, Gillett D, MacFarlane J, Van de Meulen M, Powlson A, Koulouri O, Casey R, Bashari W, Gurnell M. New types of localization methods for adrenocorticotropic hormone-dependent Cushing's syndrome. Best Pract Res Clin Endocrinol Metab 2021; 35:101513. [PMID: 34045044 DOI: 10.1016/j.beem.2021.101513] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The management of endogenous Cushing's syndrome (CS) typically involves two key steps: (i) confirmation of autonomous hypercortisolism and (ii) localization of the cause to guide treatment. Adrenocorticotropic hormone (ACTH)-dependent CS is most commonly due to a pituitary corticotrope tumor which may be so small as to evade detection on conventional magnetic resonance imaging (MRI). Although biochemical testing (e.g., corticotropin stimulation; dexamethasone suppression) can provide an indication of the likely origin of ACTH excess, bilateral inferior petrosal sinus catheterization offers greater accuracy to distinguish pituitary-driven CS [Cushing's Disease (CD)] from the ectopic ACTH syndrome [EAS, e.g., due to a bronchial or pancreatic neuroendocrine tumor (NET)]. In patients with CD, 40-50% may not have a pituitary adenoma (PA) readily visualized on standard clinical MRI. In these subjects, alternative MR sequences (e.g., dynamic, volumetric, fluid attenuation inversion recovery) and higher magnetic field strength (7T > 3T > 1.5T) may aid tumor localization but carry a risk of identifying coincidental (non-causative) pituitary lesions. Molecular imaging is therefore increasingly being deployed to detect small ACTH-secreting PA, with hybrid imaging [e.g., positron emission tomography (PET) combined with MRI] allowing precise anatomical localization of sites of radiotracer (e.g., 11C-methionine) uptake. Similarly, small ACTH-secreting NETs, missed on initial cross-sectional imaging, may be detected using PET tracers targeting abnormal glucose metabolism (e.g., 18F-fluorodeoxyglucose), somatostatin receptor (SSTR) expression (e.g., 68Ga-DOTATATE), amine precursor (e.g., 18F-DOPA) or amino acid (e.g., 11C-methionine) uptake. Therefore, modern management of ACTH-dependent CS should ideally be undertaken in specialist centers which have an array of cross-sectional and functional imaging techniques at their disposal.
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Affiliation(s)
- Russell Senanayake
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Daniel Gillett
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - James MacFarlane
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Merel Van de Meulen
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Andrew Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Olympia Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Ruth Casey
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Waiel Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mark Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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20
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Casals G, Hanzu FA. Cortisol Measurements in Cushing's Syndrome: Immunoassay or Mass Spectrometry? Ann Lab Med 2020; 40:285-296. [PMID: 32067427 PMCID: PMC7054699 DOI: 10.3343/alm.2020.40.4.285] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/20/2019] [Accepted: 02/07/2020] [Indexed: 11/19/2022] Open
Abstract
Determination of cortisol levels in the urine (24 hours urine free cortisol), saliva (late-night), or serum (total cortisol after dexamethasone suppression) is recommended to screen for Cushing's syndrome (CS). This review focuses on the differences between the frequently used cortisol-antibody immunoassay-based methods and the highly specific mass-spectrometry-based methods that are progressively being employed in clinical laboratories for CS screening. The particular characteristics of cortisol metabolism and the lack of specificity of the immunoassays cause marked differences between both methods that are in turn highly dependent on the biological matrix, in which the cortisol is measured. Understanding the origin of these differences is essential for the interpretation of these results. Although cross-reactivity with endogenous steroids leads to grossly inaccurate results of immunoassay measurements of cortisol in the saliva and urine, preliminary evidence suggests that the clinical sensitivity of CS screening using immunoassays may be similar to CS screening using mass spectrometry. However, mass spectrometry offers more accurate results and considerably reduced variation across laboratories, while avoiding false-positive results. Moreover, mass spectrometry can overcome some common diagnostic challenges, such as identification of exogenous corticosteroids or simultaneous assessment of appropriate dexamethasone levels in suppression tests. Further, comprehensive mass spectrometry-based profiling of several steroid metabolites may be useful for discriminating among different subtypes of CS. Finally, this review discusses the main preanalytical factors that could cause variations in cortisol measurements and their influence on the reliability of the results.
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Affiliation(s)
- Gregori Casals
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centrode Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), ISCIII, Madrid, Spain.
| | - Felicia Alexandra Hanzu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Endocrinology and Nutrition, Hospital Clínic, Barcelona, Spain.,Department of Medicine, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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21
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Braun LT, Rubinstein G, Zopp S, Vogel F, Schmid-Tannwald C, Escudero MP, Honegger J, Ladurner R, Reincke M. Recurrence after pituitary surgery in adult Cushing's disease: a systematic review on diagnosis and treatment. Endocrine 2020; 70:218-231. [PMID: 32743767 PMCID: PMC7396205 DOI: 10.1007/s12020-020-02432-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Recurrence after pituitary surgery in Cushing's disease (CD) is a common problem ranging from 5% (minimum) to 50% (maximum) after initially successful surgery, respectively. In this review, we give an overview of the current literature regarding prevalence, diagnosis, and therapeutic options of recurrent CD. METHODS We systematically screened the literature regarding recurrent and persistent Cushing's disease using the MESH term Cushing's disease and recurrence. Of 717 results in PubMed, all manuscripts in English and German published between 1980 and April 2020 were screened. Case reports, comments, publications focusing on pediatric CD or CD in veterinary disciplines or studies with very small sample size (patient number < 10) were excluded. Also, papers on CD in pregnancy were not included in this review. RESULTS AND CONCLUSIONS Because of the high incidence of recurrence in CD, annual clinical and biochemical follow-up is paramount. 50% of recurrences occur during the first 50 months after first surgery. In case of recurrence, treatment options include second surgery, pituitary radiation, targeted medical therapy to control hypercortisolism, and bilateral adrenalectomy. Success rates of all these treatment options vary between 25 (some of the medical therapy) and 100% (bilateral adrenalectomy). All treatment options have specific advantages, limitations, and side effects. Therefore, treatment decisions have to be individualized according to the specific needs of the patient.
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Affiliation(s)
- Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Montserrat Pazos Escudero
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Klinikum der Universität München, München, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, 72076, Tübingen, Germany
| | - Roland Ladurner
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany.
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22
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Fan Y, Li D, Liu Y, Feng M, Chen Q, Wang R. Toward better prediction of recurrence for Cushing’s disease: a factorization-machine based neural approach. INT J MACH LEARN CYB 2020. [DOI: 10.1007/s13042-020-01192-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Hasenmajer V, Sbardella E, Sciarra F, Minnetti M, Isidori AM, Venneri MA. The Immune System in Cushing's Syndrome. Trends Endocrinol Metab 2020; 31:655-669. [PMID: 32387195 DOI: 10.1016/j.tem.2020.04.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
Abstract
Cushing's syndrome (CS), or chronic hypercortisolism, induces a variety of alterations in the immune system, often leading to severe clinical complications such as sepsis and opportunistic infections. Prolonged exposure to high levels of glucocorticoids (GC), changes in the circadian rhythm, and the comorbidities associated therewith all combine to cause profound changes in the immune profile of affected patients. While traditionally associated with generalized immune suppression, such changes actually comprise a much more complex scenario, sharing traits with chronic inflammatory disorders. Persistently increased levels of interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNFα) and adipose tissue infiltration by immune cells lead to a chronic, nonresolving, inflammatory state. The combination of low-grade inflammation and selectively impaired immune response is thought to play a major role in the pathogenesis of clinical complications of CS, including diabetes, lipodystrophy, visceral adiposity, atherosclerosis, osteoporosis, and cognitive impairment. This dysregulation also explains rebound phenomena when CS is treated, involving new clinical complications sustained by an excessive immune response and autoimmunity. The aim of this review is to summarize the available evidence on the immune system in chronic hypercortisolism, while describing the main mechanisms of immune derangement and their role in the increased mortality and morbidity seen in this complex disease. A better understanding of immune system alterations in CS could help improve risk stratification, offer novel biomarkers, and provide the basis for more tailored therapies and post-remission follow-up.
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Affiliation(s)
- Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Sciarra
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Mary Anna Venneri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
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24
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Nadezhdina EY, Rebrova OY, Grigoriev AY. [The rules for predicting remission in patients with Cushing disease after successful endoscopic transnasal adenomectomy]. ACTA ACUST UNITED AC 2020; 66:70-77. [PMID: 33351315 DOI: 10.14341/probl10149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/26/2020] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND The recurrence rate after successful transnasal adenomectomy in Cushing’s disease (CD) can reach 47%. We have previously shown that patients with ACTH levels less than 7 pg/ml recurred over 3 years 4.5 times less often than patients with higher levels of ACTH, patients with cortisol levels below 123 nmol/l — in 3.4 times less than at higher values of this hormone, however, these indicators are dissociated in 41% of cases, so it is not possible use them for prediction separately. AIM To develop a method for managing patients after successful transnasal adenomectomy depending on prognosis. METHODS A monocenter retrospective comparative study included 349 patients (52 men, 297 women) with a confirmed diagnosis of CD, who underwent effective endoscopic transsphenoidal adenomectomy in 2007−2014. Various combinations of postoperative morning levels of ACTH and cortisol were analyzed. RESULTS Based on the developed forecasting methods and their best characteristics, the following rules were formulated. If postoperative morning ACTH is less than 7 pg/ml and/or postoperative morning cortisol is less than 123 nmol/l, then the patient will remain in remission for 1 year with probability of 99% (95% CI 97%–100%) and for 3 years with probability of 86% (95% CI 80%–91%). CONCLUSION The rules for predicting remission for 1 and 3 years for patients after neurosurgical treatment for CD are proposed. These rules are based on combinations of ACTH and cortisol levels.
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Affiliation(s)
| | - Olga Yu Rebrova
- Endocrinology Research Centre; The Russian National Research Medical University named after N.I. Pirogov; National Research University Higher School of Economics
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25
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Ragnarsson O. Cushing's syndrome - Disease monitoring: Recurrence, surveillance with biomarkers or imaging studies. Best Pract Res Clin Endocrinol Metab 2020; 34:101382. [PMID: 32139169 DOI: 10.1016/j.beem.2020.101382] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pituitary surgery is the first-line treatment for patients with Cushing's disease. For patients who are not considered candidates for pituitary surgery, pituitary radiation and bilateral adrenalectomy are further treatment alternatives. Not all patients are cured with pituitary surgery, and a substantial number of patients develop recurrence, sometimes many years after an apparently successful treatment. The same applies to patients treated with radiotherapy. Far from all patients are cured, and in many cases the disease recurs. Bilateral adrenalectomy, although always curative, causes chronic adrenal insufficiency and the remaining pituitary tumour can continue to grow and cause symptoms due to pressure on adjacent tissues, a phenomenon called Nelson's syndrome. In this paper the rate of recurrence of hypercortisolism, as well as the rate of development of Nelson's syndrome, following treatment of patients with Cushing's syndrome, will be reviewed. The aim of the paper is also to summarize clinical and biochemical factors that are associated with recurrence of hypercortisolism and how the patients should be monitored following treatment.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, SE-41302, Sweden.
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26
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Rubinstein G, Osswald A, Hoster E, Losa M, Elenkova A, Zacharieva S, Machado MC, Hanzu FA, Zopp S, Ritzel K, Riester A, Braun LT, Kreitschmann-Andermahr I, Storr HL, Bansal P, Barahona MJ, Cosaro E, Dogansen SC, Johnston PC, Santos de Oliveira R, Raftopoulos C, Scaroni C, Valassi E, van der Werff SJA, Schopohl J, Beuschlein F, Reincke M. Time to Diagnosis in Cushing's Syndrome: A Meta-Analysis Based on 5367 Patients. J Clin Endocrinol Metab 2020; 105:5609009. [PMID: 31665382 DOI: 10.1210/clinem/dgz136] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/24/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Signs and symptoms of Cushing's syndrome (CS) overlap with common diseases, such as the metabolic syndrome, obesity, osteoporosis, and depression. Therefore, it can take years to finally diagnose CS, although early diagnosis is important for prevention of complications. OBJECTIVE The aim of this study was to assess the time span between first symptoms and diagnosis of CS in different populations to identify factors associated with an early diagnosis. DATA SOURCES A systematic literature search via PubMed was performed to identify studies reporting on time to diagnosis in CS. In addition, unpublished data from patients of our tertiary care center and 4 other centers were included. STUDY SELECTION Clinical studies reporting on the time to diagnosis of CS were eligible. Corresponding authors were contacted to obtain additional information relevant to the research question. DATA EXTRACTION Data were extracted from the text of the retrieved articles and from additional information provided by authors contacted successfully. From initially 3326 screened studies 44 were included. DATA SYNTHESIS Mean time to diagnosis for patients with CS was 34 months (ectopic CS: 14 months; adrenal CS: 30 months; and pituitary CS: 38 months; P < .001). No difference was found for gender, age (<18 and ≥18 years), and year of diagnosis (before and after 2000). Patients with pituitary CS had a longer time to diagnosis in Germany than elsewhere. CONCLUSIONS Time to diagnosis differs for subtypes of CS but not for gender and age. Time to diagnosis remains to be long and requires to be improved.
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Affiliation(s)
- German Rubinstein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Eva Hoster
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Marco Losa
- IRCCS San Raffaele, Vita-Salute University, Milan, Italy
| | - Atanaska Elenkova
- Department of Endocrinology, Medical University-Sofia, USHATE, "Acad. Ivan Penchev"
| | - Sabina Zacharieva
- Department of Endocrinology, Medical University-Sofia, USHATE, "Acad. Ivan Penchev"
| | - Márcio Carlos Machado
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, University of Sao Paulo Medical School; Endocrinology Service, AC Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Felicia Alexandra Hanzu
- Department of Endocrinology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Stephanie Zopp
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Leah Theresa Braun
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Prachi Bansal
- Department of Endocrinology, Seth Gordhandas Sunderdas Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - María-José Barahona
- Department of Endocrinology, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
| | - Elisa Cosaro
- Section of Endocrinology Department of Medicine, University of Verona, Verona, Italy
| | - Sema Ciftci Dogansen
- Istanbul University, Istanbul Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey
| | - Philip C Johnston
- Regional Center for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, North Ireland
| | - Ricardo Santos de Oliveira
- Division of Pediatric Neurosurgery of the Department of Surgery and Anatomy, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
| | - Elena Valassi
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
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Pasternak-Pietrzak K, Moszczyńska E, Roszkowski M, Kot K, Marczak E, Grajkowska W, Pronicki M, Szalecki M. Long-term outcome in patients after treatment for Cushing's disease in childhood. PLoS One 2019; 14:e0226033. [PMID: 31830115 PMCID: PMC6907843 DOI: 10.1371/journal.pone.0226033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Cushing's disease (CD) is a rare cause of hypercortisolemia presenting a major diagnostic and therapeutic challenge. Data on pituitary function in long-term follow-up after CD treatment in childhood is limited. AIM Long-term assessment of patients of the Children's Memorial Health Institute (CMHI) after CD treatment in childhood. MATERIALS AND METHODS Retrospective analysis of 29 CD patients, mean age at the time of diagnosis 13.46 yrs. The long-term follow-up (FU) was done by: 1) obtaining the data from a patient's questionnaire (75% of adult patients); 2) using the data from the last clinic visit for patients who did not respond to the questionnaire and for current CMHI patients. The average long-term FU from transsphenoidal pituitary surgery (TSS) was 10.23 yrs. RESULTS At the latest FU: 18 patients (62%) had long-term disease remission after TSS1, 2 patients (6.9%) after TSS2, 1 patient (3.4%) after the post-TSS radiotherapy (XRT) cycle and 3 patients (10.3%) after bilateral adrenalectomy (BA). One patient (3.4%) died after TSS2 due to postoperative complications, 1 patient (3.4%) had persistent disease at latest FU, in 1 patient (3.4%) the long-term FU was not possible to perform. CD recurrence occurred in 4 out of 28 patients (14%) at an average time 3.6 yrs. from definitive treatment. One patient (3.4%) after BA was operated because of Nelson's syndrome. Two patients (6.9%) were suspected of relapse at latest assessment. At the time of the last evaluation, 17 patients (63%) were on levothyroxine therapy since definitive treatment, 16 patients (59%) were on hydrocortisone treatment, 10 patients (37%) were taking sex hormones replacement, 4 patients (15%)-antidiuretic hormone. CONCLUSIONS Relatively large number of patients after CD treatment in childhood have hormonal pituitary deficits as well as mood and cognitive disorders. CD recurrence can occur even after a long time post effective treatment.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- * E-mail:
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Marcin Roszkowski
- Department of Neurosurgery, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Karolina Kot
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Elżbieta Marczak
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
| | - Wiesława Grajkowska
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Maciej Pronicki
- Pathology Department, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children’s Memorial Health Institute (CMHI), Warsaw, Poland
- Collegium Medicum, University of Jan Kochanowski, Kielce, Poland
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Fleseriu M, Petersenn S, Biller BMK, Kadioglu P, De Block C, T'Sjoen G, Vantyghem M, Tauchmanova L, Wojna J, Roughton M, Lacroix A, Newell‐Price J. Long-term efficacy and safety of once-monthly pasireotide in Cushing's disease: A Phase III extension study. Clin Endocrinol (Oxf) 2019; 91:776-785. [PMID: 31465533 PMCID: PMC6899900 DOI: 10.1111/cen.14081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Many patients with Cushing's disease (CD) require chronic pharmacotherapy to control their hypercortisolism. We evaluated the efficacy and safety of long-acting pasireotide during a long-term extension study in patients with CD. DESIGN Open-label extension to a 12-month Phase III study of long-acting pasireotide in CD (N = 150; NCT01374906). PATIENTS Patients with mean urinary free cortisol (mUFC) ≤ upper limit of normal (ULN) or receiving clinical benefit at core study end could continue long-acting pasireotide during the extension. RESULTS Eighty-one of 150 (54.0%) enrolled patients entered the extension. Median overall exposure to pasireotide at study end was 23.9 months; 39/81 (48.1%) patients completed the extension (received ≥ 12 months' treatment during the extension and could transit to a separate pasireotide safety study). mUFC was ≤ULN in 42/81 (51.9%), 13/81 (16.0%) and 43/81 (53.1%) patients at extension baseline, month (M) 36 and last assessment. Median mUFC remained within normal limits. Median late-night salivary cortisol was 2.6 × ULN at core baseline and 1.3 × ULN at M36. Clinical improvements were sustained over time. Forty-two (51.9%) patients discontinued during the extension: 25 (30.9%) before M24 and 17 (21.0%) after M24. Hyperglycaemia-related AEs occurred in 39.5% of patients. Mean fasting glucose (FPG) and glycated haemoglobin (HbA1c ) were stable during the extension, with antidiabetic medication initiated/escalated in some patients. Sixty-six (81.5%) and 71 (88.9%) patients were classified as having diabetes (HbA1c ≥ 6.5%, FPG ≥ 7.0 mmol/L, antidiabetic medication use, or history of diabetes) at extension baseline and last assessment. CONCLUSIONS Long-acting pasireotide provided sustained biochemical and clinical improvements, with no new safety signals emerging, supporting its use as an effective long-term therapy for CD.
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Affiliation(s)
- Maria Fleseriu
- Northwest Pituitary CenterOregon Health & Science UniversityPortlandORUSA
| | | | | | | | - Christophe De Block
- Department of Endocrinology, Diabetology and MetabolismAntwerp University HospitalAntwerpBelgium
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and GenderGhent University HospitalGhentBelgium
| | | | | | - Judi Wojna
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - André Lacroix
- Centre hospitalier de l'Université de MontréalMontrealQCCanada
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Nadezhdina EY, Rebrova OY, Grigoriev AY, Ivaschenko OV, Azizyan VN, Melnichenko GA, Dedov II. Prediction of recurrence and remission within 3 years in patients with Cushing disease after successful transnasal adenomectomy. Pituitary 2019; 22:574-580. [PMID: 31506907 DOI: 10.1007/s11102-019-00985-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Some laboratory and clinical features are associated with a probability of recurrence after transnasal adenomectomy for Cushing disease (CD). However, there is no consensus on a set of predictors. Rules for prediction of recurrence were not proposed earlier. AIM To develop prediction model of recurrence/remission after successful neurosurgical treatment for CD. METHODS Retrospective single-site comparative study included 349 patients (52 men and 297 women) with a verified diagnosis of CD who underwent effective endoscopic transsphenoidal adenomectomy between 2007 and 2014. Clinical and laboratory parameters were evaluated. Laboratory tests were performed using immunochemiluminescent method. Time-to-event analysis and ROC-analysis were applied. Multivariate models were developed using logistic regression and artificial neural network (ANN). RESULTS Postoperative cortisol and ACTH levels and their combinations cannot be used for prediction of recurrence. ANN for prediction of recurrence within 3 years after successful surgery was developed. Input variables are age, duration of the disease, MRI data on adenoma, morning postoperative levels of ACTH and cortisol, output variable is binary (recurrence/remission). Predictive value for remission is 93%, 95% CI [89%; 96%], and predictive value for recurrence is 85%, 95% CI [71%; 94%]. Web-calculator based on the model is developed and free for use. CONCLUSION Effective method for prediction of recurrence and long-term remission within 3 years after successful endoscopic transsphenoidal adenomectomy is proposed.
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Affiliation(s)
- Elena Y Nadezhdina
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia.
| | - Olga Yu Rebrova
- National Research University Higher School of Economics, 20 Myasnitskaya Ul., 101000, Moscow, Russia
- Pirogov Russian National Research Medical University, 1 Ostrovitianov str., 117997, Moscow, Russia
| | - Andrey Y Grigoriev
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Vilen N Azizyan
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
| | | | - Ivan I Dedov
- Endocrinology Research Centre, 11 Dm. Ulyanova str., 117036, Moscow, Russia
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Nishioka H, Yamada S. Cushing's Disease. J Clin Med 2019; 8:jcm8111951. [PMID: 31726770 PMCID: PMC6912360 DOI: 10.3390/jcm8111951] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022] Open
Abstract
In patients with Cushing's disease (CD), prompt diagnosis and treatment are essential for favorable long-term outcomes, although this remains a challenging task. The differential diagnosis of CD is still difficult in some patients, even with an organized stepwise diagnostic approach. Moreover, despite the use of high-resolution magnetic resonance imaging (MRI) combined with advanced fine sequences, some tumors remain invisible. Surgery, using various surgical approaches for safe maximum tumor removal, still remains the first-line treatment for most patients with CD. Persistent or recurrent CD after unsuccessful surgery requires further treatment, including repeat surgery, medical therapy, radiotherapy, or sometimes, bilateral adrenalectomy. These treatments have their own advantages and disadvantages. However, the most important thing is that this complex disease should be managed by a multidisciplinary team with collaborating experts. In addition, a personalized and individual-based approach is paramount to achieve high success rates while minimizing the occurrence of adverse events and improving the patients' quality of life. Finally, the recent new insights into the pathophysiology of CD at the molecular level are highly anticipated to lead to the introduction of more accurate diagnostic tests and efficacious therapies for this devastating disease in the near future.
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Affiliation(s)
- Hiroshi Nishioka
- Department of Hypothalamic and Pituitary surgery, Toranomon Hospital, Tokyo 1058470, Japan;
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
| | - Shozo Yamada
- Hypothalamic and Pituitary Center, Moriyama Neurological Center Hospital, Tokyo 1340081, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo 1058470, Japan
- Correspondence: ; Tel.: +81-336-751-211
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31
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Pasternak-Pietrzak K, Moszczyńska E, Szalecki M. Treatment challenges in pediatric Cushing's disease: Review of the literature with particular emphasis on predictive factors for the disease recurrence. Endocrine 2019; 66:125-136. [PMID: 31701434 PMCID: PMC6838046 DOI: 10.1007/s12020-019-02036-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Cushing's disease (CD) is a rare endocrine condition caused by a corticotroph pituitary tumor that produces adrenocorticotropic hormone. The current state of knowledge of CD treatment is presented in this article including factors that can be helpful in predicting remission and/or recurrence of the disease. The primary goals in CD treatment are quick diagnosis and effective, prompt treatment as the persistent disease is associated with increased morbidity and mortality. Cooperation of a team consisting of experienced pediatrician/adult endocrinologist, neuroradiologist, transsphenoidal neurosurgeon and (if necessary) radiotherapist contribute to the best treatment effects.
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Affiliation(s)
- Katarzyna Pasternak-Pietrzak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland.
| | - Elżbieta Moszczyńska
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute (CMHI), Al. Dzieci Polskich 20, 04-730, Warsaw, Poland
- The Medicine and Health Sciences Faculty, University of Jan Kochanowski, Al. IX Wieków Kielc 19A, 25-317, Kielce, Poland
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Mayberg M, Reintjes S, Patel A, Moloney K, Mercado J, Carlson A, Scanlan J, Broyles F. Dynamics of postoperative serum cortisol after transsphenoidal surgery for Cushing's disease: implications for immediate reoperation and remission. J Neurosurg 2019; 129:1268-1277. [PMID: 29271716 DOI: 10.3171/2017.6.jns17635] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/05/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVESuccessful transsphenoidal surgery for adrenocorticotropin hormone (ACTH)-producing pituitary tumors is associated with subnormal postoperative serum cortisol levels, which may guide decisions regarding immediate reoperation. However, little is known about the detailed temporal course of changes in serum cortisol in the immediate postoperative period, and the relationship of postoperative cortisol dynamics to remission and late recurrence.METHODSA single-center retrospective cohort analysis was performed for all patients undergoing pituitary surgery from 2007 through 2015. Standardized diagnostic and treatment algorithms were applied to all patients with potential Cushing's disease (CD), including microsurgical transsphenoidal adenomectomy (TSA) by a single surgeon. All patients had serum cortisol levels drawn at 6-hour intervals for 72 hours after surgery, and were offered reoperation within 3 days for normal or supranormal postoperative cortisol levels. Primary outcomes were 6-month remission and late recurrence; secondary outcomes were persistent postoperative hypocortisolism and surgical morbidity. Discriminatory levels of postoperative serum cortisol for predicting remission were calculated at various intervals after surgery using receiver operating characteristic (ROC) curves.RESULTSAmong 89 patients diagnosed with CD, 81 underwent initial TSA for a potentially curable lesion; 23 patients (25.8%) underwent an immediate second TSA. For the entire cohort, 6-month remission was achieved in 77.8% and late recurrences occurred in 9.5%, at a mean of 43.5 months. Compared with patients with a single surgery, those with an immediate second TSA had similar rates of remission (78.3% vs 77.6%) and late recurrence (5.6% vs 11.1%). The rate of hypocortisolism for patients with 2 surgeries (12/23, 52.2%) was significantly greater than that for patients with single surgeries (13/58, 22.4%; p < 0.001). There was no difference in the incidence of CSF leaks between the first and second operations. Remission was achieved in 58 (92.1%) of 64 patients who completed the 2-surgery protocol. The temporal course of postoperative serum cortisol levels among patients varied considerably, with subnormal nadir levels < 2 μg/dl occurring between 12 hours and 66 hours. Patients achieving remission had significantly lower mean serum cortisol levels at every time point after surgery (p < 0.01). By ROC curve analysis, nadir cortisol levels < 2.1 μg/dl were predictive of 6-month remission for the entire cohort over 3 days (positive predictive value [PPV] = 94%); discriminating cortisol levels for predicting remission on postoperative day (POD) 2 were < 5.4 μg/dl (PPV = 97%), although patients with remission after postoperative cortisol levels of 2-5 μg/dl had a significantly higher rate of late recurrence.CONCLUSIONSThere is substantial variation in the temporal course of serum cortisol levels over the first 72 hours after TSA for CD, with nadir levels predictive for remission occurring as late as POD 3. Although a cortisol level of 2.1 μg/dl at any point was an accurate predictor of 6-month remission, levels less than 5.4 μg/dl on POD 2 were reasonably accurate. These data may enable decisions regarding the efficacy of an immediate second surgical procedure performed during the same hospitalization; immediate reoperation is associated with excellent remission rates and low recurrence rates in patients otherwise unlikely to achieve remission, but carries a higher risk of permanent hypocortisolism.
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Affiliation(s)
- Marc Mayberg
- 4Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Stephen Reintjes
- 3Department of Neurological Surgery, University of South Florida, Tampa, Florida
| | - Anika Patel
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | - Kelley Moloney
- 1Swedish Pituitary Center, Swedish Neuroscience Institute
| | | | - Alex Carlson
- 2Swedish Center for Research and Innovation; and
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Carr SB, Kleinschmidt-DeMasters BK, Kerr JM, Kiseljak-Vassiliades K, Wierman ME, Lillehei KO. Negative surgical exploration in patients with Cushing's disease: benefit of two-thirds gland resection on remission rate and a review of the literature. J Neurosurg 2019; 129:1260-1267. [PMID: 29219752 DOI: 10.3171/2017.5.jns162901] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 05/15/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe authors report their single-institution experience with the pathological findings, rates of remission, and complications in patients with presumed Cushing's disease (CD) who underwent a two-thirds pituitary gland resection when no adenoma was identified at the time of transsphenoidal surgery (TSS). The authors also review the literature on patients with CD, negative surgical exploration, and histological findings.METHODSThis study is a retrospective analysis of cases found in neurosurgery and pathology department databases between 1989 and 2011. In all cases, patients had been operated on by the same neurosurgeon (K.O.L.). Twenty-two (13.6%) of 161 patients who underwent TSS for CD had no adenoma identified intraoperatively after systematic exploration of the entire gland; these patients all underwent a two-thirds pituitary gland resection. A chart review was performed to assess treatment data points as well as clinical and biochemical remission status.RESULTSOf the 22 patients who underwent two-thirds gland resection, 6 (27.3%) ultimately had lesions found on final pathology. All 6 patients were found to have a distinct adrenocorticotropic hormone (ACTH) cell adenoma. Sixteen (72.7%) of the patients had no tumor identified, with 3 of these patients suspected of having ACTH cell hyperplasia. The follow-up duration for the entire group was between 14 and 315 months (mean 98.9 months, median 77 months). Remission rates were 100% (6/6 patients) for the ACTH cell adenoma group and 75% (12/16) for the group without adenoma. Overall, 18 (81.8%) of the 22 patients had no evidence of hypercortisolism at last follow-up, and 4 patients (18%) had persistent hypercortisolism, defined as a postoperative cortisol level > 5 μg/dl. Of these 4 patients, 1 was suspected of harboring a cavernous sinus adenoma, 2 were found to have lung tumors secreting ACTH, and 1 remained with an undiagnosed etiology. Rates of postoperative complications were low.CONCLUSIONSThe diagnosis and treatment of CD can be challenging for neurosurgeons, endocrinologists, and pathologists alike. Failure to find a discrete adenoma at the time of surgery occurs in at least 10%-15% of cases, even in experienced centers. The current literature provides little guidance regarding rational intraoperative approaches in such cases. The authors' experience with 161 patients with CD, when no intraoperative tumor was localized, demonstrates the utility of a two-thirds pituitary gland resection with a novel and effective surgical strategy, as suggested by a high initial remission rate and a low operative morbidity.
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Affiliation(s)
| | | | - Janice M Kerr
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Katja Kiseljak-Vassiliades
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Margaret E Wierman
- 3Division of Endocrinology, Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
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Pivonello R, Arnaldi G, Scaroni C, Giordano C, Cannavò S, Iacuaniello D, Trementino L, Zilio M, Guarnotta V, Albani A, Cozzolino A, Michetti G, Boscaro M, Colao A. The medical treatment with pasireotide in Cushing's disease: an Italian multicentre experience based on "real-world evidence". Endocrine 2019; 64:657-672. [PMID: 30968338 PMCID: PMC6551343 DOI: 10.1007/s12020-018-1818-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/12/2018] [Indexed: 12/20/2022]
Abstract
A phase III study has demonstrated that 6-month pasireotide treatment induced disease control with good safety in 15-26% of patients with Cushing's disease (CD). The aim of the current study was to evaluate the 6-month efficacy and safety of pasireotide treatment according to the real-world evidence. Thirty-two CD patients started pasireotide at the dose of 600 µg twice a day (bid) and with the chance of up-titration to 900 µg bid, or down-titration to 450 or 300 µg bid, on the basis of urinary cortisol (UC) levels or safety. Hormonal, clinical and metabolic parameters were measured at baseline and at 3-month and 6-month follow-up, whereas tumour size was evaluated at baseline and at 6-month follow-up. At baseline, 31 patients had very mild to moderate disease and 1 patient had very severe disease. Five (15.6%) patients discontinued treatment for adverse events; the remaining 27 patients (26 with very mild to moderate disease and 1 with very severe disease), reached 6-month follow-up. Considering the group of patients with very mild to moderate disease, responsiveness, defined by the normalization (<1 the upper limit of normal range, ULN) or near normalization (>1 and ≤1.1 ULN) of UC levels, was registered in 21 patients (full control in 19 and near control in 2), corresponding to 67.7% and 80.8% according to an "intention-to-treat" or "per-protocol" methodological approach, respectively. Weight, body mass index, waist circumference, as well as total and LDL-cholesterol significantly decreased, whereas fasting plasma glucose and glycated haemoglobin significantly increased. Hyperglycaemia was documented in 81.2%, whereas gastrointestinal disturbances in 40.6% of patients. In conclusion, in the real-life clinical practice, pasireotide treatment normalizes or nearly normalizes UC in at least 68% of patients with very mild to moderate disease, with consequent improvement in weight, visceral adiposity and lipid profile, despite the occurrence or deterioration of diabetes in the majority of cases, confirming the usefulness of this treatment in patients with milder disease and without uncontrolled diabetes.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy.
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Carla Scaroni
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Carla Giordano
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Salvo Cannavò
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Laura Trementino
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marialuisa Zilio
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Valentina Guarnotta
- Dipartimento Biomedico di Medicina Interna e Specialistica Di.Bi.MI.S, sezione di Endocrinologia, Diabetologia e Malattie Metaboliche, A.O.U.P. "Paolo Giaccone", Palermo, Italy
| | - Adriana Albani
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, Messina, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Sperimentale, Università "La Sapienza", Roma, Italy
| | - Grazia Michetti
- Clinica di Endocrinologia e Malattie del Metabolismo, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Marco Boscaro
- Unità Operativa di Endocrinologia, Dipartimento di Medicina, DIMED, Università di Padova, Padova, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
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Castinetti F, Brue T, Ragnarsson O. Radiotherapy as a tool for the treatment of Cushing's disease. Eur J Endocrinol 2019; 180:D9-D18. [PMID: 30970325 DOI: 10.1530/eje-19-0092] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/03/2019] [Indexed: 11/08/2022]
Abstract
Treatment of Cushing's disease (CD) is one of the most challenging tasks in endocrinology. The first-line treatment, transsphenoidal pituitary surgery, is associated with a high failure rate and a high prevalence of recurrence. Re-operation is associated with an even higher rate of a failure and recurrence. There are three main second-line treatments for CD - pituitary radiation therapy (RT), bilateral adrenalectomy and chronic cortisol-lowering medical treatment. All these treatments have their limitations. While bilateral adrenalectomy provides permanent cure of the hypercortisolism in all patients, the unavoidable chronic adrenal insufficiency and the risk of development of Nelson syndrome are of concern. Chronic cortisol-lowering medical treatment is not efficient in all patients and side effects are often a limiting factor. RT is efficient for approximately two-thirds of all patients with CD. However, the high prevalence of pituitary insufficiency is of concern as well as potential optic nerve damage, development of cerebrovascular disease and secondary brain tumours. Thus, when it comes to decide appropriate treatment for patients with CD, who have either failed to achieve remission with pituitary surgery, or patients with recurrence, the pros and cons of all second-line treatment options must be considered.
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Affiliation(s)
- Frederic Castinetti
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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Lim JS, Lee MK, Choi E, Hong N, Il Jee S, Kim SH, Lee EJ. Hormonal aggressiveness according to the expression of cellular markers in corticotroph adenomas. Endocrine 2019; 64:147-156. [PMID: 30474823 DOI: 10.1007/s12020-018-1815-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/07/2018] [Indexed: 12/29/2022]
Abstract
PURPOSE The molecular mechanisms underlying tumor growth in Cushing's disease (CD) still remain a challenge. Moreover, clinical manifestations of CD may vary depending on hormonal activity; however, factors involved in the hormonal aggressiveness of adrenocorticotropic hormone (ACTH)-secreting pituitary tumors have not been fully clarified. We investigated the association between the expression of cellular markers regarding pituitary tumor progression and initial or postoperative hormone levels in patients with CD. METHODS Tumor tissues from 28 corticotroph adenomas (female 26, male 2, mean age 39.21 ± 10.39 years) were subject to immunohistochemical study using the following antibodies: pituitary tumor-transforming gene 1 (PTTG1), cyclin D1, p16, p27, brahma related-gene 1 (Brg1), and Ki-67. We then analyzed the relationship between each cellular marker expression and hormone levels, including 24 h urinary free cortisol (UFC), plasma ACTH, and serum cortisol. RESULTS PTTG1 and Ki-67 were expressed in 100% and 50% of patients, respectively. However, the levels did not reflect initial hormonal activity. The cyclin D1-negative group showed higher serum cortisol levels compared to the cyclin D1-positive group (p = 0.01). The 24 h UFC levels were significantly higher in the p27-negative group than in the p27-positive group (p = 0.04), whereas the Brg1-positive group revealed higher serum cortisol levels than in the Brg1-negative group (p = 0.02). CONCLUSIONS Although PTTG1 and Ki-67 play an essential role in developing ACTH-secreting tumors, cyclin D1, p27, and Brg1 may be better biomarkers to determine hormonal aggressiveness of the tumor. Further research is needed to understand the influence of cellular markers on hormonal activity in CD.
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Affiliation(s)
- Jung Soo Lim
- Department of Internal Medicine, Institute of Evidence-based Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Mi-Kyung Lee
- Department of Pathology, National Health Insurance Service, Ilsan Hospital, Goyang, Gyeonggi-do, South Korea
| | - Eunhee Choi
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Namki Hong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Soo Il Jee
- Department of Pathology, National Health Insurance Service, Ilsan Hospital, Goyang, Gyeonggi-do, South Korea
| | - Sun Ho Kim
- Neurosurgery and Yonsei Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea.
| | - Eun Jig Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea.
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Serban AL, Sala E, Carosi G, Del Sindaco G, Giavoli C, Locatelli M, Arosio M, Mantovani G, Ferrante E. Recovery of Adrenal Function after Pituitary Surgery in Patients with Cushing Disease: Persistent Remission or Recurrence? Neuroendocrinology 2019; 108:211-218. [PMID: 30636245 DOI: 10.1159/000496846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cushing disease (CD) represents the principal cause of endogenous hypercortisolism. The first-line therapy of CD is surgical removal of the ACTH-secreting pituitary adenoma, which is generally followed by adrenal insufficiency (AI). OBJECTIVE To analyze the recovery of AI in patients with CD after pituitary surgery in relation with recurrence and persistent remission of CD. PATIENTS AND METHODS We performed a retrospective analysis of patients with CD who met the following inclusion criteria: adult age, presence of AI 2 months after the surgical intervention, and a minimum follow-up of 3 years after the surgical intervention. RESULTS Sixty-one patients were followed for a median of 6 years. Ten (16.4%) patients recurred during follow-up. The patients who restored adrenal function did so after a median time of 19 months, with a significantly shorter time in the recurrence group (12.5 vs. 25 months, p = 0.008). All 10 patients who recurred recovered their adrenal function within 22 months. The recovery rate of AI in the persistent remission group was 37.3% (19/51) at 3 years and 55.8% (24/43) at 5 years. In all patients the duration of AI was negatively associated with disease recurrence. CONCLUSION The duration of postsurgical AI in patients with recurrent CD is significantly shorter than that in patients with persistently remitted CD, and this parameter may be a useful predictor of recurrence. Patients showing a normal pituitary-adrenal axis within 2 years after surgery should be strictly monitored as they are at higher risk of disease relapse.
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Affiliation(s)
- Andreea Liliana Serban
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy,
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy,
| | - Elisa Sala
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Carosi
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giulia Del Sindaco
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudia Giavoli
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Marco Locatelli
- Neurosurgery Division, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Maura Arosio
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Emanuele Ferrante
- Endocrinology Unit, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
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Liu Y, Liu X, Hong X, Liu P, Bao X, Yao Y, Xing B, Li Y, Huang Y, Zhu H, Lu L, Wang R, Feng M. Prediction of Recurrence after Transsphenoidal Surgery for Cushing's Disease: The Use of Machine Learning Algorithms. Neuroendocrinology 2019; 108:201-210. [PMID: 30630181 DOI: 10.1159/000496753] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are no reliable predictive models for recurrence after transsphenoidal surgery (TSS) for Cushing's disease (CD). OBJECTIVES This study aimed to develop machine learning (ML)-based predictive models for CD recurrence after initial TSS and to evaluate their performance. METHOD A total of 354 CD patients were included in this retrospective, supervised learning, data mining study. Predictive models for recurrence were developed according to 17 variables using 7 algorithms. Models were evaluated based on the area under the receiver operating characteristic curve (AUC). RESULTS All patients were followed up for over 12 months (mean ± SD 43.80 ± 35.61). The recurrence rate was 13.0%. Age (p < 0.001), postoperative morning serum cortisol nadir (p = 0.002), and postoperative (p < 0.001) and preoperative (p = 0.04) morning adrenocorticotropin (ACTH) level were significantly related to recurrence. AUCs of the 7 models ranged from 0.608 to 0.781. The best performance (AUC = 0.781, 95% CI 0.706, 0.856) appeared when 8 variables were introduced to the random forest (RF) algorithm, which was much better than that of logistic regression (AUC = 0.684, p = 0.008) and that of using only postoperative morning serum cortisol (AUC = 0.635, p < 0.001). According to the feature selection algorithms, the top 3 predictors were age, postoperative serum cortisol, and postoperative ACTH. CONCLUSIONS Using ML-based models for prediction of the recurrence after initial TSS for CD is feasible, and RF performs best. The performance of most of ML-based models was significantly better than that of some conventional models.
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Affiliation(s)
- Yifan Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinyu Hong
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Penghao Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | | | - Yi Huang
- DHC Software Co. Ltd, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China,
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Uvelius E, Höglund P, Valdemarsson S, Siesjö P. An early post-operative ACTH suppression test can safely predict short- and long-term remission after surgery of Cushing's disease. Pituitary 2018; 21:490-498. [PMID: 30039432 PMCID: PMC6132983 DOI: 10.1007/s11102-018-0902-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study evaluates the usefulness of an ACTH suppression test shortly after surgery, and to determine optimal cut-off values of included laboratory analyses, in predicting short- and long-term remission after surgery of Cushing's disease. METHODS A 48 h suppression test with betamethasone 2 mg/day applied after 45 transphenoidal adenomectomies in 28 patients was evaluated. Receiver operating characteristic (ROC)-curves were created for the included assays: plasma cortisol, plasma adrenocorticotropic hormone (ACTH) and urinary free cortisol (UFC). Plasma levels of cortisol and ACTH were measured both at 24 and 48 h. Youden's index was used to determine cut-off with the highest sensitivity and specificity in predicting short- (3 months) and long-term (5 years or longer) remission. The area under curve (AUC) illustrated the clinical accuracy of the different assays. RESULTS Plasma cortisol after 24 h with betamethasone was most accurate in predicting both short- and long-term remission. 3 months remission with cut-off 107 nmol/L: sensitivity 0.85, specificity 0.94, positive predictive value (PPV) 0.96 and AUC 0.92 (95% CI 0.85-1). 5 years remission with cut-off 49 nmol/L: sensitivity: 0.94, specificity 0.93, PPV 0.88, AUC 0.98 (95% CI 0.95-1). Analyses of ACTH or UFC did not improve diagnostic accuracy. CONCLUSIONS A 48 h, 2 mg/day betamethasone suppression test after transphenoidal surgery of Cushing's disease could predict short- and long-term remission with a high accuracy. Suppression of plasma cortisol after 24 h with betamethasone to values excluding Cushings disease in the diagnostic setting yielded the highest accuracy in predicting long-term remission.
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Affiliation(s)
- Erik Uvelius
- Neurosurgery, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, EA-Blocket Plan 3, 221 85, Lund, Sweden.
| | - Peter Höglund
- Laboratory Medicine, Department of Clinical Chemistry & Pharmacology, Lund University, Lund, Sweden
| | - Stig Valdemarsson
- Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Peter Siesjö
- Neurosurgery, Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, EA-Blocket Plan 3, 221 85, Lund, Sweden
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Abstract
PURPOSE Surgical experience is considered paramount for excellent outcome of transsphenoidal surgery (TSS). However, objective data demonstrating the surgical success in relation to the experience of pituitary surgery units or individual experience of pituitary surgeons is sparse. METHODS Based on literature data, we have investigated the influence of experience with TSS for pituitary adenomas on endocrinological remission rates and on operative complications. The surgical experience was assessed by calculating the number of transsphenoidal operations per year. RESULTS For TSS of microprolactinomas, mean remission rates were 77% in centers with < 2 operations per year for microprolactinomas, 82% with 2-4 operations, 84% with 4-6 operations, and 91% with > 6 operations. A yearly experience with more than 10 initial operations for Cushing's disease (CD) warrants a remission rate exceeding 70%. Remission rates in CD exceeding 86% have only been reported for single surgeon series. Extraordinarily high complication rates were found in some series with < 25 yearly total operations for pituitary adenomas. Major vascular complications were less than 2% and revision rates for rhinorrhea usually < 2.5% in centers performing > 25 transsphenoidal operations per year. CONCLUSIONS We conclude that a center with experience of > 25 transsphenoidal operations for pituitary adenomas per year provides a high likelihood of safe TSS. Surgery for CD requires a particularly high level of practice to guarantee excellent remission rates. The endocrinologist has the unique opportunity to audit the surgical success by hormone measurement and to refer patients to neurosurgeons with proven excellence.
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Affiliation(s)
- Jürgen Honegger
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Florian Grimm
- Department of Neurosurgery, University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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41
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Shepard MJ, Mehta GU, Xu Z, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Kareem KA, Martinez-Moreno N, Mathieu D, McShane BJ, Blas K, Kondziolka D, Grills I, Lee JY, Martinez-Alvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Lee Vance M, Sheehan JP. Technique of Whole-Sellar Stereotactic Radiosurgery for Cushing Disease: Results from a Multicenter, International Cohort Study. World Neurosurg 2018; 116:e670-e679. [DOI: 10.1016/j.wneu.2018.05.067] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 11/25/2022]
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Ironside N, Chen CJ, Lee CC, Trifiletti DM, Vance ML, Sheehan JP. Outcomes of Pituitary Radiation for Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:349-365. [PMID: 29754636 DOI: 10.1016/j.ecl.2018.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Achievement of biochemical remission with preservation of normal pituitary function is the goal of treatment for Cushing's disease. For patients with persistent or recurrent Cushing's disease after transsphenoidal resection, radiation therapy may be a safe and effective treatment. Stereotactic radiosurgery is favored over conventional fractionated external beam radiation. Hormonal recurrence rates range from 0% to 36% at 8 years after treatment. Tumor control rates are high. New pituitary hormone deficiency is the most common adverse effect after stereotactic radiosurgery and external beam radiation. The effects of radiation planning optimization and use of adjuvant medication on endocrine remission rates warrant investigation.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Private Bag 92 024, Auckland Mail Center, Auckland 1142, New Zealand
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, 17 Floor, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei 11217, Taiwan
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Mary Lee Vance
- Division of Endocrinology and Metabolism, University of Virginia Health System, 2 Floor, Suite 2100, 415 Ray C Hunt Drive, Charlottesville, VA 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA.
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Ioachimescu AG. Prognostic Factors of Long-Term Remission After Surgical Treatment of Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:335-347. [PMID: 29754635 DOI: 10.1016/j.ecl.2018.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Transsphenoidal surgery is the main treatment of patients with adrenocorticotropic hormone (ACTH)-secreting pituitary adenomas. Although biochemical remission occurs in most patients undergoing operations at specialized centers, the recurrence risk is significant. Visualization of microadenomas on preoperative imaging and confirmation of ACTH-positive adenomas have been associated with higher remission rates. Low cortisol levels in the first 2 weeks postoperatively have been associated with durable remission; however, recurrence cannot be excluded by any cortisol threshold. The decision to perform a pituitary reoperation is based on this parameter; the protocols are institution specific. Patients with Cushing's disease warrant lifelong endocrinologic surveillance.
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Affiliation(s)
- Adriana G Ioachimescu
- Department of Medicine (Endocrinology) and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road Northeast, B6209, Atlanta, GA 30322, USA.
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44
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Zaidi HA, Wang AJ, Cote DJ, Smith TR, Prevedello D, Solari D, Cappabianca P, Quiroga M, Laws ER. Preoperative Stratification of Transsphenoidal Pituitary Surgery Patients Based on Surgical Urgency. Neurosurgery 2018; 81:659-664. [PMID: 28520927 DOI: 10.1093/neuros/nyx073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 01/31/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Currently, there is no prioritization scale available to distinguish those patients with pituitary tumors who require urgent surgical intervention from those who are candidates for elective treatment. OBJECTIVE To develop a classification system that can help primary care physicians, endocrinologists, neurosurgeons, ancillary support staff, and hospital administrators identify high-priority surgical candidates. METHODS An expert international panel of clinicians consisting of endocrinologists and neurosurgeons who are involved in the diagnosis and management of sellar disease was convened. The panel retrospectively reviewed individual experiences, including a cohort of patients operated upon for pituitary related disease at the Brigham and Women's Hospital from January 2008 to November 2015. A risk stratification schema was developed to streamline patient care pathways. RESULTS We identified 4 groups of surgical candidates with varying levels of risk, and then assigned treatment timelines and different differential diagnoses to each. The 4 groups were as follows: group A: urgent-immediate; group B: prompt-initiate treatment within 1 to 2 weeks; group C: soon-initiate treatment within 3 months; group D: elective-as soon as indicated. Among 472 patients treated at Brigham and Women's Hospital for pituitary adenomas, each was assigned to 1 of the 4 predetermined subgroups: group A, 6.8%; group B, 30.1%; group C, 31.1%; group D, 32.0%. CONCLUSIONS We developed a risk stratification schema that may serve as a platform to streamline care to the patients at highest risk. The expert opinions presented provide a basis for future studies regarding the risk prioritization of patients.
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Affiliation(s)
- Hasan A Zaidi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy J Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Cote
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio
| | | | | | - Monica Quiroga
- Department of Neurosurgery, Hospital Mexico, PINECOS, University of Costa Rica, San Jose, Costa Rica
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ironside N, Chatain G, Asuzu D, Benzo S, Lodish M, Sharma S, Nieman L, Stratakis CA, Lonser RR, Chittiboina P. Earlier post-operative hypocortisolemia may predict durable remission from Cushing's disease. Eur J Endocrinol 2018; 178:255-263. [PMID: 29330227 PMCID: PMC5812811 DOI: 10.1530/eje-17-0873] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
CONTEXT Achievement of hypocortisolemia following transsphenoidal surgery (TSS) for Cushing's disease (CD) is associated with successful adenoma resection. However, up to one-third of these patients recur. OBJECTIVE We assessed whether delay in reaching post-operative cortisol nadir may delineate patients at risk of recurrence for CD following TSS. METHODS A retrospective review of 257 patients who received 291 TSS procedures for CD at NIH, between 2003 and 2016. Early biochemical remission (serum cortisol nadir <5 μg/dL) was confirmed with endocrinological and clinical follow-up. Recurrence was detected by laboratory testing, clinical stigmata or medication dependence during a median follow-up of 11 months. RESULTS Of the 268 unique admissions, remission was recorded in 241 instances. Recurrence was observed in 9% of these cases with cortisol nadir ≤5 μg/dL and 6% of cases with cortisol nadir ≤2 μg/dL. The timing of hypocortisolemia was critical in detecting late recurrences. Morning POD-1 cortisol <3.3 μg/dL was 100% sensitive in predicting durable remission and morning POD-3 cortisol ≥18.5 μg/dL was 98.6% specific in predicting remote recurrence. AUROC analysis revealed that hypocortisolemia ≤5 µg/dL before 15 h (post-operative) had 95% sensitivity and an NPV of 0.98 for durable remission. Serum cortisol level ≤2 µg/dL, when achieved before 21 h, improved sensitivity to 100%. CONCLUSIONS In our cohort, early, profound hypocortisolemia could be used as a clinical prediction tool for durable remission. Achievement of hypocortisolemia ≤2 µg/dL before 21 post-operative hours appeared to accurately predict durable remission in the intermediate term.
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Affiliation(s)
- Natasha Ironside
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Department of NeurosurgeryAuckland City Hospital, Auckland, New Zealand
| | - Gregoire Chatain
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - David Asuzu
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Yale School of MedicineNew Haven, Connecticut, USA
| | - Sarah Benzo
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
| | - Maya Lodish
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Susmeeta Sharma
- Pituitary Endocrinology SectionMedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Lynnette Nieman
- National Institute of Diabetes and Digestive and Kidney DiseasesNational Institutes of Health, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Endocrinology and GeneticsEunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Russell R Lonser
- Department of Neurological SurgeryWexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Prashant Chittiboina
- Surgical Neurology BranchNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
- Neurosurgery Unit for Pituitary and Inheritable DiseasesNational Institute of Neurological Diseases and Stroke, Bethesda, Maryland, USA
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Aranda G, Fernandez-Ruiz R, Palomo M, Romo M, Mora M, Halperin I, Casals G, Enseñat J, Vidal O, Diaz-Ricart M, Hanzu FA. Translational evidence of prothrombotic and inflammatory endothelial damage in Cushing syndrome after remission. Clin Endocrinol (Oxf) 2018; 88:415-424. [PMID: 29154455 DOI: 10.1111/cen.13521] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 11/09/2017] [Accepted: 11/14/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Sustained evidence from observational studies indicates that after remission of Cushing syndrome (CS) a cardiovascular risk phenotype persists. Here, we performed a translational study in active CS and CS in remission (RCS) to evaluate the subclinical cardiometabolic burden and to explore the direct pro-inflammatory and prothrombotic potential of their sera on the endothelium in an in vitro translational atherothrombotic cell model. PATIENTS Cross sectional study. The groups were (n = 9/group): I. RCS; II. Active CS (ACS) and III. Controls (CTR), all matched for age, body mass index, sex, without other hormonal deficits. DESIGN We evaluated in vivo: cardiometabolic profile; endothelial markers (sVCAM-1, NO); endothelial dysfunction (FMD); intima-media thickness and body composition (DEXA). In vitro endothelial cells (EC) were exposed to sera taken from the different subjects to evaluate inflammatory EC response (tisVCAM) and thrombogenicity of the generated extracellular matrix (ECM): von Willebrand factor (VWF) and platelet reactivity. RESULTS Three of the 9 RCS subjects were on glucocorticoid replacement therapy (GC-RT). Patients on GC-RT had a shorter period of time in stable remission. In vivo analysis ACS showed typically metabolic features, while cardiometabolic markers reached statistical significance for RCS only for Hs-CRP (P < .01). In vitro:EC exposed to ACS and RCS sera displayed increased tisVCAM-1 (P < .01 for ACS and P < .05 for RCS vs CTR), VWF (P < .01 for ACS and P < .05 for RCS vs CTR) and platelet adhesion on ECM (P < .01 for ACC and P < .05 for RCS vs CTR). No statistically significant differences were observed between GC-RT RSC and RCS without GC-RT. CONCLUSIONS The sera of premenopausal women with CS in remission, without atherothrombotic disease, contain circulatory endothelial deleterious factors with a direct thrombogenic and pro-inflammatory endothelial effect that could increase cardiovascular risk.
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Affiliation(s)
- Gloria Aranda
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Marta Palomo
- Josep Carreras Leukemia Research Institute, Hospital Clinic/University of Barcelona, Barcelona, Spain
- Department of Hemotherapy and Hemostasis, Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Mónica Romo
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
| | - Mireia Mora
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic of Barcelona, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Irene Halperin
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic of Barcelona, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Gregori Casals
- Biochemistry and Molecular Genetics Service, Hospital Clinic of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Joaquim Enseñat
- University of Barcelona, Barcelona, Spain
- Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Oscar Vidal
- University of Barcelona, Barcelona, Spain
- Department of Endocrine Surgery, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Maribel Diaz-Ricart
- Department of Hemotherapy and Hemostasis, Hospital Clinic of Barcelona, IDIBAPS, Barcelona, Spain
| | - Felicia A Hanzu
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic of Barcelona, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
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Qiao N. Outcome of endoscopic vs microsurgical transsphenoidal resection for Cushing's disease. Endocr Connect 2018; 7:R26-R37. [PMID: 29311226 PMCID: PMC5763281 DOI: 10.1530/ec-17-0312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/28/2017] [Indexed: 11/08/2022]
Abstract
INTRODUCTION It is unclear whether the proportions of remission and the recurrence rates differ between endoscopic transsphenoidal surgery (TS) and microscopic TS in Cushing's disease (CD); thus, we conducted a systematic review and meta-analysis to evaluate studies of endoscopic TS and microscopic TS. METHODS We conducted a comprehensive search of PubMed to identify relevant studies. Remission and recurrence were used as outcome measures following surgical treatment of CD. RESULTS A total of 24 cohort studies involving 1670 adult patients were included in the comparison. Among these studies, 702 patients across 9 studies underwent endoscopic TS, and 968 patients across 15 studies underwent microscopic TS. Similar baseline characteristics were observed in both groups. There was no significant difference in remission between the two groups: 79.7% (95% CI: 73.1-85.0%) in the endoscopic group and 76.9% (95% CI: 71.3-81.6%) in the microscopic group (P = 0.485). It appears that patients who underwent endoscopic surgery experience recurrence less often than patients who underwent microscopic surgery, with recurrence proportions of 11.0% and 15.9%, respectively (P = 0.134). However, if follow-up time is taken into account, both groups had a recurrence rate of approximately 4% per person per year (95% CI: 3.1-5.4% and 3.6-5.1%, P = 0.651). CONCLUSIONS We found that remission proportion and recurrence rate were the same in patients who underwent endoscopic TS as in patients who underwent microscopic TS. The definition of diagnosis, remission and recurrence should always be considered in the studies assessing therapeutic efficacy in CD.
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Affiliation(s)
- Nidan Qiao
- Department of NeurosurgeryHuashan Hospital, Fudan University, Shanghai, China
- Harvard Medical SchoolBoston, Massachusetts, USA
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Bansal P, Lila A, Goroshi M, Jadhav S, Lomte N, Thakkar K, Goel A, Shah A, Sankhe S, Goel N, Jaguste N, Bandgar T, Shah N. Duration of post-operative hypocortisolism predicts sustained remission after pituitary surgery for Cushing's disease. Endocr Connect 2017; 6:625-636. [PMID: 28912338 PMCID: PMC5640573 DOI: 10.1530/ec-17-0175] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 09/14/2017] [Indexed: 11/08/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the primary treatment modality for Cushing's disease (CD). However, the predictors of post-operative remission and recurrence remain debatable. Thus, we studied the post-operative remission and long-term recurrence rates, as well as their respective predictive factors. METHODS A retrospective analysis of case records of 230 CD patients who underwent primary microscopic TSS at our tertiary care referral centre between 1987 and 2015 was undertaken. Demographic features, pre- and post-operative hormonal values, MRI findings, histopathological features and follow-up data were recorded. Remission and recurrence rates as well as their respective predictive factors were studied. RESULTS Overall, the post-operative remission rate was 65.6% (early remission 46%; delayed remission 19.6%), while the recurrence rate was 41% at mean follow-up of 74 ± 61.1 months (12-270 months). Significantly higher early remission rates were observed in patients with microadenoma vs macroadenoma (51.7% vs 30.6%, P = 0.005) and those with unequivocal vs equivocal MRI for microadenoma (55.8% vs 38.5%, P = 0.007). Patients with invasive macroadenoma had poorer (4.5% vs 45%, P = 0.001) remission rates. Recurrence rates were higher in patients with delayed remission than those with early remission (61.5% vs 30.8%, P = 0.001). Duration of post-operative hypocortisolemia ≥13 months predicted sustained remission with 100% specificity and 46.4% sensitivity. Recurrence could be detected significantly earlier (27.7 vs 69.2 months, P < 0.001) in patients with available serial follow-up biochemistry as compared to those with infrequent follow-up after remission. CONCLUSION In our study, remission and recurrence rates were similar to that of reported literature, but proportion of delayed remission was relatively higher. Negative/equivocal MRI findings and presence of macroadenoma, especially those with cavernous sinus invasion were predictors of poor remission rates. In addition to early remission, longer duration of post-operative hypocortisolism is an important predictor of sustained remission. Regular biochemical surveillance may help in identifying recurrence early.
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Affiliation(s)
- Prachi Bansal
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Anurag Lila
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Manjunath Goroshi
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Swati Jadhav
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nilesh Lomte
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Kunal Thakkar
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Atul Goel
- Department of NeurosurgerySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Abhidha Shah
- Department of NeurosurgerySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shilpa Sankhe
- Department of RadiologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Naina Goel
- Department of PathologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Neelam Jaguste
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Tushar Bandgar
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nalini Shah
- Department of EndocrinologySeth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
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49
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Feng M, Liu Z, Liu X, Bao X, Yao Y, Deng K, Xing B, Lian W, Zhu H, Lu L, Wang R. Diagnosis and Outcomes of 341 Patients with Cushing's Disease Following Transsphenoid Surgery: A Single-Center Experience. World Neurosurg 2017; 109:e75-e80. [PMID: 28951275 DOI: 10.1016/j.wneu.2017.09.105] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Transsphenoid surgery (TSS) is a standard treatment modality for Cushing's disease (CD). However, postoperative remission and recurrence rates vary among studies. Here we analyze the diagnosis and outcomes of 341 patients with a preoperative diagnosis of CD undergoing TSS in a single center over a 3-year period. METHODS A total of 341 patients were enrolled. Clinical manifestations, imaging results, laboratory workups, and results of inferior petrosal sinus sampling (IPSS) were obtained. Outcomes were obtained with a follow-up length from 12 to 36 months. RESULTS The tumors were mainly of Knosp level 0 (68.57%). The sensitivity of MRI, combined low-dose and high-dose dexamethasone suppression test and IPSS in the diagnosis were 90.83%, 88.53% and 95.57%. The concordance of lateralization by MRI and by IPSS were 78.96% and 61.34% compared with surgery. 2. OUTCOMES The overall remission rate was 78.89% (N = 289). Patients undergoing the first TSS (N = 234) had a remission rate of 86.36% for macroadenomas (N = 22) and 83.2% for microadenomas (N = 212). Patients undergoing a second TSS (N = 55) had lower rate of remission of 50.00% for macroadenomas (N = 6) and 61.22% for microadenomas (N = 49). For patients with invasive tumors, the overall remission rate was 26.92% (N = 26), 20.0% for macroadenomas (n = 20) and 50.0% for microadenomas (N = 6). The recurrence rate was 2.42%. CONCLUSIONS Pituitary imaging, endocrinological workups and IPSS are sensitive and specific diagnostic modalities for CD, but the lateralization efficacy of MRI and IPSS are unsatisfactory. A higher rate of remission relies on gross resections of tumors.
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Affiliation(s)
- Ming Feng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ziyuan Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiaohai Liu
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yong Yao
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Kan Deng
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lin Lu
- Department of Endocrinology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China.
| | - Renzhi Wang
- Department of Neurosurgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China.
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50
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Aranda G, Careaga M, Hanzu FA, Patrascioiu I, Ríos P, Mora M, Morales-Romero B, Jiménez W, Halperin I, Casals G. Accuracy of immunoassay and mass spectrometry urinary free cortisol in the diagnosis of Cushing's syndrome. Pituitary 2016; 19:496-502. [PMID: 27259502 DOI: 10.1007/s11102-016-0730-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE Urinary free cortisol (UFC) determination by highly specific methods as mass spectrometry instead of commercially available antibody-based immunoassays is increasingly recommended. However, clinical comparisons of both analytical approaches in the screening of Cushing's syndrome (CS) are not available. The aim of this study was to evaluate the diagnostic value of mass spectrometry versus immunoassay measurements of 24 h-UFC in the screening of CS. METHODS Cross-sectional study of 33 histologically confirmed CS patients: 25 Cushing's disease, 5 adrenal CS and 3 ectopic CS; 92 non-CS patients; and 35 healthy controls. UFC by immunoassay (UFCxIA) and mass spectrometry (UFCxMS), urinary free cortisone (UFCo) and UFC:UFCo ratio were measured, together with creatinine-corrected values. Sensitivity, specificity, AUC and Landis and Koch concordance index were determined. RESULTS AUC for UFCxIA and UFCxMS were 0.77 (CI 0.68-0.87) and 0.77 (CI 0.67-0.87) respectively, with a kappa coefficient 0.60 and strong Landis and Koch concordance index. The best calculated cutoff values were 359 nmol/24 h for UFCxIA (78 % sensitivity, 62 % specificity) and 258.1 nmol/24 h for UCFxMS (53 % sensitivity, 86 % specificity). The upper limit of UFCxIA and UCFxMS reference ranges were 344.7 and 169.5 nmol/24 h respectively. Sensitivity and specificity for CS diagnosis at these cutpoints were 84 and 56 % for UFCxIA and 81 and 54 % for UFCxMS. CONCLUSIONS According to our data, both methods present a very similar diagnostic value. However, results suggest that lower cutoff points for mass spectrometry may be necessary in order to improve clinical sensitivity.
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Affiliation(s)
- G Aranda
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
| | - M Careaga
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
| | - F A Hanzu
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - I Patrascioiu
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
| | - P Ríos
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
| | - M Mora
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - B Morales-Romero
- Biochemistry and Molecular Genetics Service, Hospital Clinic Universitari, IDIBAPS, CIBERehd, Villarroel 170, 08036, Barcelona, Spain
| | - W Jiménez
- Biochemistry and Molecular Genetics Service, Hospital Clinic Universitari, IDIBAPS, CIBERehd, Villarroel 170, 08036, Barcelona, Spain
- Biomedicine Department, University of Barcelona, Barcelona, Spain
| | - I Halperin
- Group of Endocrine Disorders, IDIBAPS, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Clinic, Barcelona, Spain
- Centro de Investigación en Red, CIBERDEM, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - G Casals
- Biochemistry and Molecular Genetics Service, Hospital Clinic Universitari, IDIBAPS, CIBERehd, Villarroel 170, 08036, Barcelona, Spain.
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